Home Fire Safety Program Application 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:
Home Fire-Safety Program Application
Residents of Bergen County or the City of Paterson can have 10-year lithium-battery smoke alarms installed in their homes at no cost through Rebuilding Together North Jersey’s Home-Fire Safety Program. Low-income seniors and people with disabilities may also be eligible for free carbon-monoxide detectors. Residents selected will be contacted for an appointment and must be home at the time of installation.

Household Information

Resident(s) name, street address, town:
Name:* Address:*
Town:* State:*       Zip:*
Home phone: Cell phone:
Work phone: Email:*    
Date of birth: Co-applicant's date of birth:
Do you own this home? How many people live in this home?
Are you or a member of your household a Veteran/member of the Armed Forces?

Fire Safety Information

Smoke Alarms

Do you currently have smoke detectors/alarms?
Yes, on all floors Yes, on some floors Yes, but they don't work
No, I do not have any smoke detectors/alarms 
Does anyone in the home have a hearing impairment (requiring a special smoke alarm)?  

Carbon-monoxide Alarms

Do you have any carbon-monoxide detectors/alarms?
Yes   No   I don't know
If Yes that Number of alarms

Property Information

How long have you lived in the home: Number of bedrooms:
Number of stories:

Financial Information

Total household income: $ monthly OR $ annually.
(To qualify, annual income should not exceed $47,000 for one person; $53,700 for two people; $60,400 for three people; $67,100 for four people; or $72,500 for five people in the household.)

Race and Ethnicity Data (optional)

Providing the following information is optional and is requested for HUD reporting purposes only.
Information provided will have absolutely no influence on your eligibility for service.

Check all categories that apply.

Name(s) of Occupant(s) Age
Hispanic
White
Asian
Black or African American
Native American or Alaska Native
Native Hawaiian or Other Pacific Island
Other: Please Specify
Totals

Statement of Eligibility

I, , have asked Rebuilding Together to provide fire-safety repairs to my home at (address)
in (city) . This same house is my full-time residence. All the information submitted on my application is complete and correct to the best of my knowledge.
Signed: Date:
(Applicant)
Date:
(Co-applicant)

To be considered for our Fire Safety Program, mail or fax this completed application to:

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