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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. We ask that you and /or any able-bodied members of your household participate alongside volunteers in repairs to the best of your abilities. Please understand that we receive many applications and applying does not guarantee work will be done.
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Name
*
First
Last
Phone
*
Email
*
Best way to contact you
*
Phone
Email
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?
*
Friend
Radio
Church
Internet
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
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?
*
Own
Rent
Do you Own or Rent your land?
*
Own
Rent
Name on Deed
*
First
Last
Address (if different) on Deed
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Do you plan to sell your home within the next
*
Do not plan to sell
2 years
5 years
Others
Is the home your current residence?
*
Yes
No
Third Choice
Is this home your only residence?
*
Yes
No
Third Choice
Applicant has lived at the residence for ____years and ____ months.
*
Do you own other property?
*
Yes
No
Third Choice
Are any family members (deceased or living) currently serving or have served in the military?
*
Yes
No
Third Choice
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?
*
Yes
No
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
*
Social Security
SSI
Annuities
Pensions
Gross Wages
Other Be Specific
Other Source of Income
Amount
*
How Often
*
Weekly
Monthly
Yearly
Name
First
Last
Choose Income Source
Social Security
SSI
Annuities
Pensions
Gross Wages
Other Be Specific
Other Source of Income
Amount
How Often
Weekly
Monthly
Yearly
Name
First
Last
Choose Income Source
Social Security
SSI
Annuities
Pensions
Gross Wages
Other Be Specific
Other Source of Income
Amount
How Often
Weekly
Monthly
Yearly
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
*
Single Family
Townhouse
Mobile 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)
*
None
City Water
Well
Does your wastewater go to (choose one)
*
City Sewer
Septic
other
Do you have Central Air?
*
Yes
No
Third Choice
Do you have Central Heat?
*
Yes
No
Third Choice
Type of heat
*
Electric
Natural Gas
Propane
Kerosene
Wood
None
Area to be repaired: Brief description of work you need assistance with:
*
Are you or other household members able to assist with repairs?
*
Yes
No
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
*
Date Format: 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
*
Yes
No
Name
This field is for validation purposes and should be left unchanged.
Donate today & help us build a strong community
If you prefer to send a check our mailing address is: 516 Project, Inc. 10908 Courthouse Rd. Suite 102148 Fredericksburg, Va. 22408
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