Date: / Chambersburg Project, Inc.
Homeowner Application 2016
Full Name: /
Age:

Last

/

First

/

M.I.

Applicant Information

Spouse’s: /
Age:

Last

/

First

/

M.I.

Address:

Street Address

/

Apartment/Unit #

City

/

State

/

ZIP Code

Home Phone: /
Cell Phone:
Boro/Township: /
Do you own your own home?
/ YES / NO
/ If yes, how long?
Total # of people living in the home? / Total # under 18 living in the home?
Type of Home: / Single Family Dwelling / / Two Story / Mobile Home / One Story / Other:
Names and ages of children under 18 living in the home:
Name: / Age: / Name: / Age:
Name: / Age: / Name: / Age:
List anyone else living in the home but not listed above:
Name: / Age: / Name: / Age:

Needed Construction or Repairs

Interior Painting:
Exterior Painting:
Roof Repair:
Ramp or Steps:
Porch Repair:
Yard Work:
Other:

If you have any questions or need assistance in completing this application, please call our office at: 717-261-0045

Personal Data

Please complete:

Total Gross Annual Household Income (Yearly)
$9,999 or less / / $10,000-$14,999 / $15,000-$19,999
$20,000-$24,999 / / $24,999-29,999 / $30,000 +
Sources of Income and Amounts (Monthly)
Wages /
$
/ Unemployment Compensation / $
Workman’s Compensation /
$
/ Child Support / $
Alimony / $ / / Public Assistance / $
Social Security /
$
/ S.S. Disability / $
Rental Income /
$
/ Pensions/IRA/401K / $

Employment Status

Are you: Employed? Unemployed? Retired? Disabled?
Homeowner’s Employment Status:
Spouse’s Employment Status:
Monthly Household Expenses
Mortgage /

$

/ Credit Cards / $
Car Payment / $ / / Utilities / $
Medical Bills /

$

/ Other Loans / $
Have you applied to other agencies for home repair assistance? / Yes / No
If yes, what agencies have you applied to?
Have you received assistance for home repairs from any agency? / Yes / No
If yes, what type of assistance?

Disclaimer and Waiver of Liability

By signing this application, I understand that this application is not a guarantee that my home will be selected for repairs. I understand that repairs to my home will be done by teenagers with adult supervision. I understand that some work may not be completed due to limited funds, difficulty of construction or bad weather. I agree to be home during the repairs and provide restroom facilities and a working telephone while repairs are being completed.

I (We) the homeowner(s) of the above listed property agree to hold harmless and indemnify Chambersburg Project, Inc., its directors, officers, employees, sponsoring organizations and all volunteers and assign any and all liability of whatever kind or nature, either in law or in equity, which arises from the repairs made to the property by Chambersburg Project, Inc. and its volunteers. I (We) understand that this release discharges the Chambersburg Project, Inc. from any liability that I (we) may have against Chambersburg Project, Inc. with respect to property damage, illness, bodily injury, or death resulting from the repairs performed Chambersburg Project.

Signature: /

Date:

Please mail completed applications to:

Chambersburg Project, Inc., Building Team, 6816 Back Lane, Waynesboro, PA, 17268