P.O. Box 331
Germantown, MD 20875-0331
(301) 947-5770
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Hearts & Hands, Inc. P.O. Box 331 Germantown, MD 20875-0331 (301) 947-5770 |
H O M E R E P A I R A P P L I C A T I O N
Hearts & Hands, Inc. is a not for profit agency that provides services at no cost to the homeowner. An all-volunteer staff made up of both adults and youth does the work. The criteria for servicing families or individuals are based on federal guidelines, which takes into consideration income and family size.
Please print. All information is kept confidential. Complete and return to the above address. If you have any questions please call (301) 947-5770.
Name of Homeowner(s):___________________________________________________________
Address:________________________________________________________________________
City:__________________________________County:__________________ Zipcode:_________
Phone number:______-______-________ If you do not have a telephone, please give a phone number where a message may be left for you:_____________________________
Do you own your home? Yes_____ No_____
Please give specific directions to your home:__________________________________________
______________________________________________________________________________
______________________________________________________________________________
Names and ages of all persons living in the home:______________________________________
______________________________________________________________________________
______________________________________________________________________________
Is anyone residing in the home disabled or have special medical needs? If so, indicate special needs (wheelchair, walker, blind, hearing impaired, etc.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Homeowner(s) Name:_____________________________________________________________
TYPE OF REPAIRS TO BE CONSIDERED:
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Type of Repair |
Brief Description |
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Electrical |
Yes No |
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Plumbing |
Yes No |
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Exterior painting |
Yes No |
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Interior painting |
Yes No |
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Walls repairs |
Yes No |
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Floor repairs |
Yes No |
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Roof repairs |
Yes No |
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(Wheelchair ramp, Grab bars, etc.) |
Yes No |
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Yard work |
Yes No |
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Other |
Yes No |
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The combined ADJUSTED GROSS INCOME (wages, social security, SSI, AFDC, other) for the homeowner(s) of this home is (please check):
_____Less than $16,500 per year
_____Between $16,500 and $27,550 per year
_____Between $27,550 and $33,450 per year
_____More than $33,450 per year
I understand that documentation will be required to verify income such as the most recent income tax return. W-2 Forms and other information.
________________________________________________________Date: _____________
________________________________________________________Date: _____________
Signatures of homeowner(s)
If this form is prepared by other than homeowner please complete the following:
Agency: ______________________________Contact person: _____________________
Phone number: _______ - _____________________
Is the homeowner aware of this application? ______________
For office use only:
Date application received: _______________
Date of home visit for review: ____________
Date of approval or denial: _______________
Referred to different agency: _____________
Date work completed:__________________