Critical Home Repair Online Application - Habitat for Humanity of the Charlotte Region

application

Please check on of the following (Por favor, Marque uno de los siguientes):

language

I understand and can complete this application provided in English

No entiendo la solicitud prevista en inglés y pedir una solicitud en español

Other

Other preferred language

Spanish

French

Chinese

Vietnamese

Contact Name

First Last

Contact Email

Enter Email Confirm Email

Contact Phone

Program Participation Acknowledgment

All approved families for the Critical Home Repair program will be asked to complete 50 hours of community service as a way to pay it forward.

All approved families for the Critical Home Repair program will be asked to sign a Deed Restriction committing to using your home as your main residence for 5 years.

More information about community service options and the deed restriction is available on the Critical Home Repair program eligibility & criteria page.

If you haven't already viewed this short video explaining the Critical Home Repair program and its participation criteria, please take a few minutes to watch before continuing:

Acknowledgment of Program Participation Criteria(Required)

I have read and reviewed the Critical Home Repair program participation details

Is this Critical Home Repair application for yourself or someone else?(Required)

Myself

Someone Else

(If for someone else, what is your name?)

First Last

(If for someone else, what is your phone number?)

(If for someone else, what is your contact email address?)

(If for someone else, what is your relationship to the homeowner?)

Applicant Information

Applicant Name(Required)

First Middle Initial Last

Date of Birth(Required)

Social Security Number(Required)

show Social Security Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number (preferred)(Required)

Phone Number (secondary, if applicable)

Do you have an email address?(Required)

Yes

No

Email

Enter Email Confirm Email

Marital Status(Required)

Married

Unmarried (includes single, divorced, widowed)

Separated

Have you served in the U.S. Armed Forces?(Required)

Yes

No

Please upload a copy of your DD-214 form, if available

Max. file size: 100 MB.

How did you hear about the Critical Home Repair program?(Required)

Saw a repair in my neighborhood

Received something in the mail

Habitat Charlotte Region website

Social media

Friend/Family suggestion or referral

Church/Faith group

Other

Name of the person that referred you:

We recently launched an incentive program for those who refer Critical Home Repair applicants. If you let us know who referred you, they could be eligible to receive a Home Depot gift card (while supplies last)!

Phone number of the person that referred you:

Email address of the person that referred you:

Enter Email Confirm Email

Do you have a co-applicant for this Critical Home Repair project?(Required)

Yes

No

A co-applicant is defined as another household member whose name is also on the deed to the home.

Co-Applicant Information

Co-Applicant Name(Required)

First Middle Initial Last

Co-Applicant Date of Birth(Required)

Co-Applicant Social Security Number(Required)

show Co-Applicant Social Security Number

Co-Applicant Phone Number(Required)

Does Co-Applicant have an email address?(Required)

Yes

No

Co-Applicant Email(Required)

Enter Email Confirm Email

Co-Applicant Marital Status(Required)

Married

Unmarried (includes single, divorced, widowed)

Separated

Has Co-Applicant served in the U.S. Armed Forces?(Required)

Yes

No

Please upload a copy of Co-Applicant's DD-214 form, if available

Max. file size: 100 MB.

Other Household Members

Please be prepared to provide full names and dates of birth for all members of the household, excluding Applicant and Co-Applicant, if applicable.

Additional number of people living in the household, NOT including Applicant (and Co-Applicant, if applicable)(Required)

If more than 6, please call the Critical Home Repair Hotline at 704.716.5639 to speak with a member of our team.

Household Member #1 Name(Required)

First Last

Household Member #1 Date of Birth(Required)

Household Member #2 Name(Required)

First Last

Household Member #2 Date of Birth(Required)

Household Member #3 Name(Required)

First Last

Household Member #3 Date of Birth(Required)

Household Member #4 Name(Required)

First Last

Household Member #4 Date of Birth(Required)

Household Member #5 Name(Required)

First Last

Household Member #5 Date of Birth(Required)

Household Member #6 Name(Required)

First Last

Household Member #6 Date of Birth(Required)

Habitat for Humanity of the Charlotte Region Authorization to Release Information

Please be advised that as a condition of participating in Habitat for Humanity of Charlotte Region's (“Habitat”) Homeownership or Critical Home Repair programs, we may share information with and obtain information from third party entities, which may include but is not limited to lending institutions, grant funders, consumer credit reporting agencies, motor vehicles, the criminal justice system, and employers and landlords. You understand that the aforementioned information may be evaluated to determine your eligibility to partner with Habitat. Habitat is providing you with this notice and authorization in compliance with the Fair Credit Reporting Act.

GENERAL RELEASE

I release Habitat and its officers, directors, employees, agents, all other persons, employers, businesses, schools, consumer information agencies, records search firms, and other entities of and from any and all potential liability arising from inquires by Habitat and its agents concerning the verifications described above and/or the compilation or use of such information and reports regarding me.

CERTIFICATION OF INFORMATION SUBMITTED TO HABITAT

I acknowledge that I have carefully reviewed the information on this form in its entirety. I also certify that all of the information provided by me on the application and subsequent authorization form are true and complete to the best of my knowledge, and may be shared with third parties. I further understand that any omission of fact or false or misleading information provided by me whether verbally or written, may result in the automatic withdrawal of my application and termination of my participationand partnership with Habitat.

By clicking "I Agree" at the bottom of this page, you consent use your electronic signature to sign any document or communication and to receive electronic delivery of any document or communication. You understand that your electronic signature is legally binding, just as if you had signed a paper document.

Applicant Full Name(Required)

Today's Date(Required)

Co-Applicant Full Name(Required)

Today's Date(Required)

Habitat for Humanity of the Charlotte Region Privacy Statement

At Habitat for Humanity of the Charlotte Region, we are committed to keeping your information private.

We recognize the importance applicants, Homeowners-in-Process, tenants, and homeowners place on the privacy and confidentiality of their information. While new technologies allow us to more efficiently serve our customers, we are committed to maintaining privacy standards that are synonymous with our established and trusted name.

When collecting, storing, and retrieving applicant, Homeowner-in-Process, tenant, or homeowner data, such as tax returns, pay stubs, credit reports, employment verifications, and payment histories, internal controls are maintained throughout the process to ensure security and confidentiality.

We collect non-public personal information about you from the following sources: information about your transactions with us, our affiliates, or others; and information we receive from a consumer credit reporting agency and public records including background checks.

Habitat for Humanity of the Charlotte Region employees and volunteers are subject to a written policy regarding confidentiality, and access to applicant data is restricted to staff and volunteers on a need-to-know basis.

Information is used for lawful business purposes and is never shared with third parties without your consent, except as permitted by law. Habitat for Humanity has no affiliates or marketing experts with whom we share personal information.

If any partner family or individual feels that a conflict has occurred that needs attention or resolution from the staff at Habitat for Humanity of the Charlotte Region, they should file a grievance with the Director of Critical Home Repair, Family Services Isela Walldez.

Habitat for Humanity of the Charlotte Region is an Equal Housing Opportunity Provider. We are pledged to the letter and spirit of U.S. Policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status, or national origin.

Applicant Full Name(Required)

Co-Applicant Full Name(Required)

Critical Home Repair Application

Two important reminders:

application

Program Participation Acknowledgment

Applicant Information

Co-Applicant Information

Other Household Members

Repairs Needed

Applicant Income

Co-Applicant Income

Household Member Income

Budget

Declarations

Declarations (Co-Applicant)

Habitat for Humanity of the Charlotte Region Authorization to Release Information

Habitat for Humanity of the Charlotte Region Privacy Statement

Voluntary Demographic Information for Government Monitoring Purposes