Home Repair

Pre-Screen Application

Please complete the form below and if you qualify, we will send you our formal application. Items marked * are required.

    Applicant

    Co-Applicant

    Other Persons Living in Household

    Other Family Members In Area

    Description of Home Repairs Needed

    A Brush with Kindness is a Habitat for Humanity program for Seniors, Veterans, and Low-Income Homeowners. Please note: Renters are not eligible to participate in this program.

    Applicant Name: ______________________________________________________________________________
    Street Address: _______________________________________________________________________________
    City, State, Zip: _______________________________________________________________________________
    Phone: _________________________________ Email: _______________________________________________
    Date of Birth: ____________________________ Did you or your family serve in Military? (Y/N): _____________
    How did you hear about this program? ____________________________________________________________

    Home Repairs or ADA Modifications Needed: (Please check those that apply)

    Safety improvements:
    □ Grab bars
    □ Non-slip stair treads
    □ Railings in halls/stairs
    □ Ramps
    □ Basic home repairs
    □ Secure door/ window locks

    Mobility modifications:
    □ Widen doorways
    □ Install easy-to-use cabinet pulls
    □ Lever-style door handles/faucets
    □ Minor bathroom modification

    Weatherization enhancements:
    □ Replace caulking or sealing
    □ Weather strips to doors
    □ Window replacements
    □ Insulation

    Additional exterior examples:
    □ Exterior landscaping
    □ Exterior
    Other (please describe): ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________
    Approximate Household Income (Your total income for all persons living in the home): $_________________/yr.

    To be eligible to participate in the program, homeowners must provide supporting documentation of:
    o All household income
    o Current homeowner’s insurance declaration pages

    I understand that by submitting this application, I am authorizing Housatonic Habitat for Humanity to evaluate my need for A Brush with Kindness home repair or ADA modification. I understand that this evaluation will include personal visits and income verification. I have answered all questions truthfully. I understand that by completing this application, I am submitting myself and all persons listed to a background check by Housatonic Habitat for Humanity.

    Applicant Signature: _________________________________ Date: _____________________________________________