Homeowner Application. Critical Needs Project can be printed from HERE and
mail to Rebuilding Together North Jersey’s office at PO Box 1389, Ridgewood NJ 07451-1389.
Also, you may complete our online application:
Homeowner Application. Critical Needs Project.
Homeowner(s) name & address:
Name:* Address:*
Town:* State:*           Zip:*
Home phone: Cell phone:
Work phone: Email:*      
Date of birth: Co-applicant's date of birth:
Secondary/Emergency contact (family member or close friend) living at another address:
Name:* Address:*
Town:* State:*           Zip:*
Phone: Email:*      
Relationship to homeowner:
How many people live in this home?      Do you own other property?    Yes No
Have you received assistance from Rebuilding Together (formerly Christmas in April) before?    Yes No
If yes, in what year did we work on your house?
Do you have a PAAD card?    Yes No
Are/were you or an immediate family member a Veteran/member of the Armed Forces?    Yes No
Who?       Number of years served:       Where/What branch?   

Rebuilding Together relies on volunteers and community involvement. If your home is selected, able-bodied family members age 14 and older are expected to help with tasks that may be suited to their abilities, including helping and thanking volunteers. (Lack of family or friends to help will not disqualify you.) Please initial to indicate your agreement:

	I understand that I am required to volunteer to the best of my ability and that adult
	family members or friends on site during the workday will also participate.  Initial

If someone other than the homeowner prepares this application, or helps the homeowner fill it out, please complete the following:

Name of person preparing/assisting with application:
Relationship to applicant:
Address: Phone:

Race and Ethnicity Data (optional)

We request that race and ethnicity information be provided by persons applying for services from Rebuilding Together North Jersey for HUD-reporting purposes only. Although providing the information on this page is optional, our compiling of such data is expected to benefit the delivery of HUD-affiliated services. Information provided (or waiving the option to report this information) will have absolutely no influence on your eligibility for services provided by Rebuilding Together North Jersey.

  Check all categories that apply.
Name(s) of Occupant(s) Age
Black or African American
Native American or Alaska Native
Native Hawaiian or Other Pacific Island
Other: Please Specify

The above household information has been freely and accurately reported, to the best of my knowledge.

Signed: Date:
I choose to exercise my option not to report the requested information.
Signed: Date:

Documents required to prove ownership, income and residence

Please submit copies of the following documents when you return the application. Applications submitted without these documents will not be considered. If you must send originals, please enclose a self-addressed stamped envelope for their return.

1.Proof of ownership (submit one only):
 • a copy of your current property tax bill
 • OR a copy of the deed to your property
2.Proof of income (submit one only) for all residents in your home
 • a copy of your (and/or their) W2 or benefit/retirement statement(s)
 • OR a copy of your (and/or their) last year's Federal tax return (1040)
 • OR a copy of your (and/or their) SSI Statement
3.Proof of residence (submit one only)
 • a copy of a recent telephone bill OR cable TV bill
 • OR a copy of a recent PSE&G

Property Information

Year purchased: Number of bedrooms: Number of stories:
Do you have homeowner's insurance?    Yes No
If yes, please answer the following:    Insurance Company:    Policy #:

Desired Repairs

Please note that funds for emergency repairs are limited and the number of applications we receive may exceed our budget or abilities. Therefore Rebuilding Together Bergen County cannot guarantee that every home will be selected or every item will be addressed. However, so that we can evaluation your situation, please be specific about your situation.

Accessibility Modifications (ramp, railings, door-widening, etc.):

Roofing: Please describe the problem, area of the roof, whether or not it is actively leaking, etc.

Heat / Hot Water / Plumbing:

Appliances (e.g., non-working stove, refrigerator):

Financial Information

Income sourcesYour income (monthly)Total household income (monthly)
Employment$ $
Social Security$ $
SSI$ $
Pension$ $
Retirement$ $
VA$ $
Rental$ $
Total monthly income: $ $

Household expenses/liabilities (monthly)

Property tax$
Mortgages (first/second liens)$
Phone, cable, garbage$
Medical (include prescription costs)$
Insurance (homeowner's, health, auto)$
Total monthly household expenses:$

Homeowner's Statement of Eligibility

I, , have asked Rebuilding Together to provide repairs to my home at in Bergen County or the City of Paterson. I understand that Rebuilding Together is funded by charitable donations and grants to provide assistance to the elderly, disabled, veterans or low-income families with children who have no other means to afford home repairs.
I also understand that Rebuilding Together North Jersey is obligated to use its charitable donations and grants only for assistance to eligible homeowners. In addition, I understand that to knowingly submit false information is considered fraud and punishable under law. By signing my name to this statement, I guarantee that I am eligible to receive this assistance, as follows:
1. All the information submitted on my Homeowner Application is complete and correct. Initial
2. I am the sole owner of the home at the above address, or I share ownership with persons who are also eligible to receive this assistance. Initial
3. This same house is my full-time residence. Initial
4. I will not sell, rent or transfer ownership of this house for five years after completion of repairs Initial
5. I understand that when work is completed Rebuilding Together may put a 5-year lien on the property in the amount of the labor and materials put into the home; and I will be responsible for reimbursing that amount if I sell, rent or accept a contract for sale of the home while work is being completed or within five years after work is completed. Initial
6. I, my spouse, partner and/or any other owners of my home have no other financial resources to afford the services that I have requested. Initial
7. I authorize Rebuilding Together and its representatives to complete paperwork required to obtain building permits necessary to repair my home. Initial
8. I understand that Rebuilding Together works primarily on Saturdays. Initial
9. I understand that Rebuilding Together North Jersey is a neighbor-helpingneighbor organization, and I will do everything possible to get my friends and family to help on the workday. Initial

We cannot assist everyone who applies, so please tell us why you think Rebuilding Together should choose you and your family. What impact would our work have on your life? Tell us about your situation at home and your activities in your neighborhood and community.

Signed: Date:
Signed: Date:
(Printed name of witness)

HUD Low-Income Guidelines

Rebuilding Together North Jersey uses the following low-income guidelines set by the Department of Housing and Urban Development for Bergen and Passaic Counties:

1 person - $47,0005 people - $72,500
2 people - $53,7006 people - $77,850
3 people - $60,4007 people - $83,250
4 people - $67,1008 people - $88,600

To see if you qualify, please calculate your total annual household income and compare it to the maximum annual income listed above for the number of people who live in your home.

THERE IS NO APPLICATION FEE REQUIRED TO APPLY TO RECEIVE ASSISTANCE FROM REBUILDING TOGETHER. Rebuilding Together has not authorized any other person or entity to act as its agent for purposes of this application and any fees or costs associated with this application paid by the applicant to any such person or entity are not fees or costs charged by Rebuilding Together.

Please complete this application and return it with the supporting home-ownership documents to:

Rebuilding Together North JerseyFAX: 201-857-3909
P.O. Box 1389
Ridgewood, NJ 07451-1389Questions? Call: 201-447-8886
Email: info@RTNorthJersey.org