VOLUNTEER REPAIR PROGRAM
Application Form (Revised 8/11) Greater Fredericksburg
A BRUSH WITH KINDNESS
Homeowner's Name Home Phone
Address Work Phone
City, State Zip Code Cell/Other Phone
Email Veteran [ ] Yes [ ] No
DATE OF BIRTH:___/____/______ GENDER: [ ] Male [ ] Female DISABLED: [ ] Yes [ ] No
Have you ever applied for this program before? [ ] Yes [ ] No
If yes, provide date(s) of previous application(s):_________________________________________
(Please note: Prior application does not disqualify you from participation.)
List the total per month income below. Include income received by/for each person in the household.
Amount: $ Name: Source:
Utilities: Credit Card(s): Car Payment: Other:
List the name and age of all household residents below
1. Homeowner’s Name 3.
Date house was built_____________________ Is this a mobile home? [ ] Yes [ ] No
Type of Work Needed: (Check all that apply and number in priority order.)
□ Exterior Paint □ Landscaping □ Deck (Repair/Replace) □ Handicap Ramp
□ Replace Windows □ Install Weather Stripping □ Repair or Replace Flooring
□ Other (Specify)____________________________________________________________________
1. Applicant must provide proof of income (W2, recent pay stubs, SSI letter, etc.) and must provide proof of homeownership (copy
of deed, mortgage payment, tax record, etc.). If the applicant’s residence is a mobile home but is parked on land owned by a
second party, attach the land PLAT.
2. This documentation must be attached to the application and will be discussed with a Habitat representative when the home visit is
1. Applicant must reside in the home.
2. Applicant must agree that the use of a volunteer work force to provide labor for housing repairs is acceptable to the applicant and
by signature below the applicant hereby authorizes the use of such volunteer labor on the applicant’s house.
3. Applicant family is required to partner with Greater Fredericksburg Habitat for Humanity by fulfilling a minimum number of sweat
4. Only the work that is included in the Scope of Work will be done during the time required to do the stated project. No add-ons.
Any additional work will have to be requested under a separate project.
By signature below, the undersigned applicant hereby agrees to the above requirements.
PRIVACY ACT AGREEMENT
I understand that by filing an application for the A Brush With Kindness program, I am
authorizing Greater Fredericksburg Habitat for Humanity to evaluate my actual need for
home repair, my ability to repay the no-interest loan, and my willingness to be a partner
family. I understand that the evaluation will include personal home visits.
I have read this agreement and understand that my application and all the attached
documentation will be maintained in the Habitat files whether I am approved for the ABWK
program or not. I understand that information contained in the application packet will be kept
in utmost confidence and not shared with any other person or organization outside the
Greater Fredericksburg Habitat for Humanity.
This is to acknowledge that I have read and understand the details of the privacy statement.
Applicant Signature Date
Co-Applicant Signature Date