We can provide assistance

We encourage you to complete this application if the person seeking help meets the following eligibility criteria:

Owns their home
Has homeowner's insurance
Resides in the zip code area of Appleton, Combined Locks, Kaukauna, Kimberly, Little Chute, Menasha or Neenah
Has low income based on county/federal guidelines
Is 60 years or older and/or is disabled

Please note that submission of this form constitutes an application and is not indicative of the final selection.

You will hear back from us within 4-6 weeks on whether your home will receive an evaluation. If so, our preview team will visit your home to determine the extent of repairs needed.

If selected, repairs will be made during the coming year.

Selection of homes is at the sole discretion of the RTFV Board and is based on providing safe and habitable conditions along with the availability of volunteers and funds.

If the repairs or home modifications needed are urgent or emergency services may be needed, please indicate this in the section Other Information.

Do you need help with repairs and updates to your home? Do you know someone in need of home repair help? Then please fill out and submit our on-line application.
Applicant Name:
Age:
Co-applicant Name:
Age:
Address:
City:
State:	WI
ZIP:
Phone:
How many years have you lived at this house?

Is the applicant or co-applicant currently employed? If yes, indicate employer.
Yes No


Please list everyone, including children, other than the applicant(s) who live in this house. (Please call us after submitting this form if there are more than three people.)
Person 1:
Age:
Relationship:
Employed?	Yes No

Person 2:
Age:
Relationship:
Employed?	Yes No

Person 3:
Age:
Relationship:
Employed?	Yes No

Please provide information about your closest living relative.
Name:
Phone:
Relationship:

Do you own your home?	Yes No
Home insurance carrier:
What style of home?	Ranch 2 (or more) story Trailer home
Plan to sell home in next 18 months?	Yes No

Please provide your total monthly gross (before taxes & expenses) household income, including wages, social security, pension and disability income.

Check if you receive any of the following benefits.
SSI SSDI Food stamps Home or community based services

If you, or anyone else living in your home, is disabled, please check the appropriate box below.
Sight impairment Hearing impaired Walker Wheelchair Other impairment

Please indicate the number of people in your household according to each of these ethnic categories.
Caucasian/white:
African American:
Native American:
Hispanic/Latino:
Asian/Pacific Islander:
Other:

Please indicate the repairs you seek to improve your safety, personal independence and warmth of your home.


How did you hear about us at Rebuilding Together Fox Valley? Did someone refer you to us?


If someone other than the homeowner is preparing this application, please complete the following.
Preparer's Name:
Phone:
Relationship or Organization:

If selected, you will be required to provide proof of income, home ownership and homeowner's insurance. Do you certify that the above information is true and correct to the best of your knowledge? Do you agree to authorize RTFV to check any references necessary to complete the processing of this application for the purpose of receiving housing rehabilitation through Rebuilding Together Fox Valley? RTVF pledges to keep information confidential and that it will be used only to determine eligibility for home improvement work. Will you give RTFV volunteers or designated personnel permission to inspect your home for purposes of home selection and repair? *If you agree to all of this, please check below.*
Yes, I agree No

We can provide assistance

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