Rebuilding Together - Sacramento

Homeowner Application

We are sorry -- the online application is no longer functional. Please return to our website homepage and download a paper application. Complete and Mail to P.O. Box 255584, Sacramento, CA  95825 or fax to (916) 731-7077. Or you can Scan and Email to julieo@rebuildingtogethersacramento.org.


* Required field

Basic Information
* Application Date
What Program are you applying for?
* First Name
* Last Name
Middle Name
Address 1
Address 2
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email Address
Are you a veteran?
Yes No
Are you the widow of a veteran?
Yes No
Ethnicity
Gender
Date of Birth
How did you hear about us?
If other, where did you hear about Rebuilding Together?
Personal Contact
Name
Relationship
Phone
Application
Is this a mobile home?
Yes No
Are you employed?
Yes No
Number of persons in household
Is this household headed by a female?
Yes No
Total annual income for all residents
$
Source of Income
Do you own this home?
Yes No
Years in home
Do you have renters?
Yes No
If yes, how much rent do they pay?
What is renter's gross annual income?
List your top three safety modifications/home repair needs
Needs Assessment
Do you use a wheelchair?
Yes No
Do you use a walker?
Yes No
Can you get in and out of the tub/shower with ease?
Yes No
Can you navigate steps easily?
Yes No
Can you get on and off the toilet with ease?
Yes No
Do you have a mat in the tub/shower?
Yes No
Can you rise from a sitting position easily?
Yes No
How many smoke detectors do you have?
How many carbon monoxide detectors do you have?
Do you have any disabilities?
Yes No
If yes, please describe any disabilities
Home Energy Conservation Needs
Have SMUD or PG&E installed energy conservation measures (weather stripping, caulking, water heater blanket, etc.) in your home in the last five years?
Yes No
Are your doors and/or windows drafty?
Yes No
Do you currently use compact fluorescent bulbs?
Yes No
Residents Living With You
This entry will be deleted on submit!
 
Name
Relationship
Age
Disabled
Yes No
Veteran
Yes No
Employed
Yes No