HOMEOWNER APPLICATION & REFERRAL FORM

Name of Homeowner(s):____________________________________________________________

Address:______________________________________Phone:_____________________________

Is homeowner: Elderly_____ Disabled______ Moderate to lower income____________

Fixed income______ other______ approx. monthly household income______________

Pertinent information concerning family situation (include number and age of all  people residing in the home):___________________________________________________________________________

_________________________________________________________________________________

General condition of the house and description of work to be done (please be specific): _________________________________________________________________________________

_________________________________________________________________________________

How will the homeowner and family members be able to assist in the repair of their house? _________________________________________________________________________________

_________________________________________________________________________________

(Use other side for additional comments, if necessary)

Is this a referral? ________ If so, is the homeowner aware of this referral?_____

If yes to both, please explain that this is a one-day program, the work is done by volunteers and that
able-bodied adult residents living with the homeowner are requested to work on REBUILDING TOGETHER day.

Name of person submitting this referral (optional):__________________________________________

Agency:___________________________Date:___________________Phone:___________________

PLEASE SEND THIS FORM TO: REBUILDING TOGETHER, c/o Liz Tracy, Manchester Parks & Recreation Department, 41 Center Street, PO Box 191, Manchester, CT 06045-0191. For info, call 647-3167. (Priority is given to fixed or moderate-to-lower income, elderly or disabled people who cannot do the repairs or improvements themselves and have no able-bodied family members who might do the work. Recipients are asked to welcome volunteers into their homes and share this "neighborhood helping neighbor" program.)