Rebuilding Day 1999:application

This information is to help us identify good candidates for assistance by Christmas in April

  1. Please provide the following contact information:
    Name
    Street address
    Address
    City
    State
    ZIP
    Work Phone
    Home Phone
    E-mail
  2. Enter your Social Security Number in the space provided below.


  3. How many people in your household ?


  4. How many bedrooms in your home ?


  5. How many other rooms in your home ?


  6. Do you own your home?

    Yes No

  7. What is your monthly mortgage payment ?


  8. What is your average monthly cost of utilities?


  9. How many years have you lived at this address ?


  10. Briefly describe the work to be done on your home.

    The house will require:

    Electrical work Plumbing

    Carpentry Roofing

    Masonry Painting

    Landscaping Windows

    Give us some description of the most significant work needed:

  11. What is your gross monthly income?


  12. What other family income is there?


  13. How much other income do you have ?


  14. Any child support, AFDC, Social Security, SSI, pension or alimony income (describe) ?


  15. Describe any other income in the space provided below.


  16. How much do you hold in savings accounts ?


  17. How much in certificates of deposit?


  18. How much in checking accounts ?


  19. How much in money market, credit union or other accounts?


  20. Do you pay alimony or child support ?

    Yes No

  21. If so, what is the monthly payment ?


  22. Please list any loans, including mortgages, along with the monthly payment and the balance now due.


  23. In what ways will you and your family help, in partnership with our volunteers, in fixing up your home?


Copyright Christmas in April Greater Portland 1998.
Last revised: September 30, 1998