Name of Homeowner(s): ___________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Phone: _______________________

Is the homeowner: elderly_____ disabled____ low income: _____Veteran__________

Is there proof of homeownership? _________________________ (If so, please attach)

Number of people living in household: (Continue on reverse if necessary)

Name                                         Age      Relationship       Type of Income & Amount  
___________________________   ____     ___________    ______________________
___________________________   ____     ___________    ______________________
___________________________   ____     ___________    ______________________
___________________________   ____     ___________    ______________________

Assets:
     
Savings ____________________
Checking ___________________
Stocks, Bonds________________
Real Estate __________________
Other:______________________
Please provide proof of income and assets with this application.

Pertinent information concerning family situation and general condition of home:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Description of work needed to be done:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the homeowner aware of this referral?  Yes ____  No ____
Name of person submitting this referral: ________________________________________
Agency:_________________________________________________________________
Address: ________________________________________________________________
Phone : _____________________
Date: _______________________
PLEASE SEND THIS FORM TO: REBUILDING TOGETHER, KENT COUNTY, MD
                                                       P.O. Box 180,  CHESTERTOWN, MARYLAND  21620-0180