Home Rehabilitation Application Form

To qualify for a Habitat for Humanity Bermuda home rehabilitation, applicants must complete this form fully and accurately. All information provided on this form will be kept confidential.

APPLICANT INFORMATION

First name

Last name

Address

Age

Phone

Email

Marital Status

Married

Single

Divorced

Widowed

Dependents names and ages

HOUSING INFORMATION

Home Status

Own

Rent

Please provide the names of all homeowners listed on the deed

If you are renting, please provide the details regarding your landlord:

Name

Landlord

Phone

Email

If you are renting, please provide a copy of the Rental Agreement with this application

Number of bedrooms

Kitchen

Living Room

Dining Room

Bathroom(s)

Please describe the condition of your current dwelling and why you need Habitat home improvement:

FINANCIAL INFORMATION

Total Net Monthly Income of all members of the household:

Primary Income Earner Name

Net Income

Secondary Income Earner Name

Net Income

Do you have a family member who can provide financial or technical support (ie carpentry skills)?

Yes

No

In order to be considered for a Habitat Bermuda home improvement, you and your family must be willing to complete a certain amount of “sweat equity” hours towards the project. Your help in improving your home and the houses of others is called “sweat equity” and may include clearing lots, removing junk or garbage from the home, or willingness to volunteer in the Habitat ReStore of other approved activities.

Please indicate if you are willing to complete the required number of sweat equity hours

Yes

No

If no, please indicate why

Please provide the details of any special financial circumstances that may qualify you for Habitat home improvement:

AUTHORIZATION AND RELEASE

I understand that by completing and signing this application, I am authorizing Habitat for Humanity Bermuda to evaluate my actual need for a Habitat Home Improvement and my willingness to be a partner family. I understand that the evaluation will include personal visits. I have answered all questions on the application truthfully.

Signature

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Date

Month

Day

Year

Building strength, stability and self-reliance through shelter

Home Rehabilitation Application Form

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