Get Assistance from The 516 Project

For a downloadable application click here…

516 Project Application

Dear Homeowner: 516 Project’s mission is to share the love of Jesus through our actions and words by helping families in need. Together with volunteers, churches and businesses we impact our community to glorify God through service to others. Our main focus is projects that impact a family being warm, safe and dry. Please understand that we receive many applications and applying does not guarantee work will be done.

Step 1 of 4

Name*
First Last
Phone*
Email*
Best way to contact you*
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mailing Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency contact Name
First Last
Emergency Contact Phone
How did you hear about 516 Project?*
- Referral
- Friend
- Radio
- Church
- Other
Referred by: (Church / Agency)
Contact Person (From Church / Agency)
First Last
Phone (Church / Agency)
Email (Church / Agency)
Have you applied before?*
- Yes
- No
Have we visited your home ?*
- Yes
- No
My main need is:*
Please give a brief description of your situation and why you need assistance:

HOUSEHOLD INFORMATION
Age of home or Year built*
Do you Own or Rent your home?*
Do you Own or Rent your land?*
Name on Deed*
First Last
Address (if different) on Deed
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you plan to sell your home within the next*
Is the home your current residence?*
Is this home your only residence?*
Applicant has lived at the residence for ____years and ____ months.*
Do you own other property?*
Are any family members (deceased or living) currently serving or have served in the military?*
Number of Veterans in the household:
Yrs. of service:
Number of household member with disabilities:
Please explain all disabilities or special needs:*
- Hearing / Vision Impaired
- Wheelchair / Walker
- Mentally Impaired
- Other
- Does Not Apply
Please complete the following for all members of the household. Please list ALL income sources (Employer, Social Security, AFDC, VA Benefits, Disabilities, Child Support, Pensions, Medicare, Medicaid,etc.)
Total Household Income*
Amount of Monthly Mortgage Payments?*
Average Utility Bills?*
Do you have homeowner’s insurance?*
Homeowner's Insurance Company*
INCOME VERIFICATION:Please list all of your income sources for all members of your household below and indicate if amounts are for weekly, biweekly, monthly, or annual payments:
Name*
First Last
Choose Income Source*
Other Source of Income
Amount*
How Often*
Name
First Last
Choose Income Source
Other Source of Income
Amount
How Often
Name
First Last
Choose Income Source
Other Source of Income
Amount
How Often
I understand that I may have to show.. Copies of documents such as an Employer Pay Slip, a document from Social security that shows the monthly or annual amount received, W-2 form, or 1099 Form and your most recent financial information.*
I agree

HOME REPAIR INFORMATION:
Type of Home*
Other:
Total number of Bedrooms
Total number of Bathrooms
Sq Ft of the whole house
Electrical service provider*
Water supply to house (choose one)*
Does your wastewater go to (choose one)*
Do you have Central Air?*
Do you have Central Heat?*
Type of heat*
Area to be repaired: Brief description of work you need assistance with:*
Are you or other household members able to assist with repairs?*
If you are unable to assist in repairs, please explain why?

HOMEOWNER DISCLOSURE AGREEMENT
My signature indicates that all the above statements and information provided are accurate and complete.*
I agree
I certify that I do not have the financial means to perform the repairs for which I am applying.*
I agree
I HAVE READ the information provided by 516 Project representatives and volunteers (skilled and unskilled). Most volunteers are not professionals. They may not be able to complete all repairs at my home.*
I agree
I understand that there is no cost to the homeowner for these repairs.*
I agree
I understand that I am expected to participate with volunteers at my home to the best of my ability, and the adult family members or friends on site during work days will also participate.*
I agree
I give 516 Project permission to share this document with other providers, or non-profit organizations who might be able to assist with this application.*
I agree
Applicants Signature Please type your name:*
First Last
Date*
MM slash DD slash YYYY
An assessment team member may call to schedule an inspection of your home and get more details of work requirements. You will be notified by phone or mail whether or not you are selected.
** If this form has been prepared by someone other than the homeowners, or if assistance has been given to the homeowner, please complete the following:
Name or preparer
First Last
Relationship
Agency
Phone
Email
Is the homeowner aware of this application*
Name
This field is for validation purposes and should be left unchanged.

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516 Project, Inc.
10908 Courthouse Rd. Suite 102148
Fredericksburg, Va. 22408

516 Project Application

Step 1 of 4

HOUSEHOLD INFORMATION

Please complete the following for all members of the household. Please list ALL income sources (Employer, Social Security, AFDC, VA Benefits, Disabilities, Child Support, Pensions, Medicare, Medicaid,etc.)

INCOME VERIFICATION:Please list all of your income sources for all members of your household below and indicate if amounts are for weekly, biweekly, monthly, or annual payments:

HOME REPAIR INFORMATION:

HOMEOWNER DISCLOSURE AGREEMENT

An assessment team member may call to schedule an inspection of your home and get more details of work requirements. You will be notified by phone or mail whether or not you are selected.