Application

Applicant Name (required)

Co-Applicant Name

Applicant Email *

HOME ADDRESS:*

Street

City

Zipcode

PHONE (xxx-xxx-xxxx):

Home*

Cell

Work

Please list ALL persons who reside on the property. (Leave blank if none.)

Resident 1:

1. Name Age Sex: M/F malefemale

Relationship to the Applicant

Over 62 or Disabled? (check both if both apply) Over 62Disabled

Resident 2:

2. Name Age Sex: M/F malefemale

Relationship to the Applicant

Over 62 or Disabled? (check both if both apply) Over 62Disabled

Resident 3:

3. Name Age Sex: M/F malefemale

Relationship to the Applicant

Over 62 or Disabled? (check both if both apply) Over 62Disabled

Resident 4:

4. Name Age Sex: M/F malefemale

Relationship to the Applicant

Over 62 or Disabled? (check both if both apply) Over 62Disabled

Resident 5:

5. Name Age Sex: M/F malefemale

Relationship to the Applicant

Over 62 or Disabled? (check both if both apply) Over 62Disabled

Is the title to your dwelling in the applicant’s or co-applicant’s name? *yesno

If no, please explain:

(Applicant must have legal title to the property and be legally able to authorize repairs.)

How long have you owned this home?*

How did you hear about the BOZEMAN SUNRISE ROTARY FIX UP FESTIVAL?*

What health, safety, or energy conservation repair needs does your home require? *

(Repair costs are limited to $2,000 in materials and several volunteers should be able to be complete the repairs within 8 hours.)

What is your total Gross Annual Income:*

List ALL sources and GROSS Amounts of income into the household in the past 3 months.

(Include Workers’ Comp., Soc Sec., Unemployment Benefits, Pension, SSI, VA, Wages, Dividends, Interest, Child Support, Alimony, Employment; Self-Employment, etc.) You may be asked to verify Gross Income with letters and check stubs. (If none, leave blank.)

Income #1 Type of Income Source of Income
Amount of Income Frequency of Income
Gross 3 Month Total for Income Type #1:

Income #2 Type of Income Source of Income
Amount of Income Frequency of Income
Gross 3 Month Total for Income Type #2:

Income #3 Type of Income Source of Income
Amount of Income Frequency of Income
Gross 3 Month Total for Income Type #3:

Income #4 Type of Income Source of Income
Amount of Income Frequency of Income
Gross 3 Month Total for Income Type #4:

Please list all liquid assets

(Cash, Checking, Stocks, Bonds, CD’s, Savings, IRA’s, Mutual Funds, real estate excluding your own home.) You may be asked to supply verification of liquid assets. (If none, leave blank.)

Asset #1 Type of Asset Source of Asset
Net Value or Balance of Asset

Asset #2 Type of Asset Source of Asset
Net Value or Balance of Asset

Asset #3 Type of Asset Source of Asset
Net Value or Balance of Asset

Asset #4 Type of Asset Source of Asset
Net Value or Balance of Asset

Please look over your form and make sure all the appropriate fields are filled in. The fields marked with “*” are required. If you’re ready to send the form, click the submit box below:

-As funds and volunteers are limited priority for repairs is given to elderly and disabled households. Scope, type and amount of repairs and final selection of homes to be repaired is the decision of the Bozeman Sunrise Rotary club. Homeowner must be in residence during the repairs.

Call Caren at HRDC, 406-585-4866 with any questions.