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Heat's On
Hammer with a Heart Homeowner Application
in
Hammer with a Heart
Homeowner Name:
*
Age:
*
Other Household Members
Name (2):
Age (2):
Name (3):
Age (3):
Name (4):
Age (4):
Name (5):
Age (5):
Contact Info
Address:
*
City:
*
State:
*
Zip Code:
*
Daytime Phone:
*
Evening Phone:
*
Best Time To Contact:
e-Mail:
Have you received any Project Home Services?:
*
Yes
No
If so, select those you've received::
Home Repair
Hammer with a Heart
Paint-a-thon
Weatherization
Home Information
Do you own this home?:
*
Yes
No
Approximate Value of Your Home:
*
General Condition of Your Home:
*
Poor
Fair
Good
Very Good
Description of Work Needed:
*
Describe the all of tasks that need to be done, even if we cannot do them all. Please be as specific as possible.
Event Information
Will you or your family members be available to help with the work on the day of the event?:
*
Yes
No
Volunteers will need to be inside your home during the day's events. Can the volunteers use the bathroom facilities in your home:
*
Yes
No
Can you provide refreshments during the day for volunteers? (water, soda, etc.):
*
Yes
No
Household Income
Please fill out all income received by your household. You will be asked to provide verification of this income during the selection process.
Interest and Dividends:
$
annually
Child Support:
$
annually
Business Profit:
$
annually
Pensions & Annuities:
$
annually
Rental Income:
$
annually
Social Security:
$
annually
Salaries:
$
annually
Any Public Assistance:
$
annually
Estate or Trust Income:
$
annually
Total Income:
*
$
annually
Disabilities
Are you or anyone in your household disabled?:
*
Yes
No
If so, who?:
What is the nature of the disability?:
Photographs/Interviews:
Yes
No
To solicit volunteers and funds for Hammer with a Heart, it is essential that Project Home publicize this event. Are you willing to be photographed and interviewed regarding your involvement with Hammer with a Heart.
How did you hear about this program?:
*
Ethnic Background:
Black
American Indian
Hispanic
Asian
White
Please check the category that represents your ethnic background? (Response to this question is optional)
Please type your full name:
*
By typing my name, I recognize that in consideration of my voluntary participation in Hammer with a Heart, which is a charitable event, I agree to release all sponsoring organizations (including their officers, employees, members, and agents, all other volunteers, and homeowner participants) from all liability whatsoever which may arise out of or be connected with participation in this event and all activities related to it. I certify that I am the current owner-occupant of a single-family home in Dane County. I declare that the above household income for all members of the household is correct. I understand that in order to participate in Hammer with a Heart I may need to sign a five-year forgivable loan for the assessed value of the repairs performed, secured by a mortgage against the home. This loan will be forgiven at a rate of 20% per year provided that I own and occupy the home as my principal residence for five years. If I sell the home, transfer ownership, take equity out of, or move out prior to the five year period, the prorated balance of the loan will be due and payable to Project Home, Inc. The assessed value of the repairs will be determined after the home inspection has been completed and before said loan agreement is signed. I, the undersigned, certify subject to disqualification, that this information is true and correct to the best of my knowledge and believe, and that the provisions stated are accepted and agreed to.
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