Rebuilding Together - Sacramento

Homeowner Application

Thank you for your interest in our program.  Please fill out the application and we will call you to set up an appointment if you are eligible for our program.  Please note that we need proof of income with each application.  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?
YesNo
Are you the widow of a veteran?
YesNo
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?
YesNo
Are you employed?
YesNo
Number of persons in household
Is this household headed by a female?
YesNo
Total annual income for all residents
$
Source of Income
Do you own this home?
YesNo
Years in home
Do you have renters?
YesNo
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?
YesNo
Do you use a walker?
YesNo
Can you get in and out of the tub/shower with ease?
YesNo
Can you navigate steps easily?
YesNo
Can you get on and off the toilet with ease?
YesNo
Do you have a mat in the tub/shower?
YesNo
Can you rise from a sitting position easily?
YesNo
How many smoke detectors do you have?
How many carbon monoxide detectors do you have?
Do you have any disabilities?
YesNo
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?
YesNo
Are your doors and/or windows drafty?
YesNo
Do you currently use compact fluorescent bulbs?
YesNo
Residents Living With You
This entry will be deleted on submit!
 
Name
Relationship
Age
Disabled
YesNo
Veteran
YesNo
Employed
YesNo