APPLICATION

Name*

First Last

Date of Birth*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Is this form being completed by the Homeowner or a Representative on the homeowners hehalf?*

Homeowner

Someone Else

Representative Name*

First Last

Representative Phone*

RepresentativeRelationship*

RepresentativeOrganization

Who referred you for the home repair services (if different than above)?

Marital Status*

Do you own the home you live in?*

Yes

Are your property taxes paid to date?*

Yes

Are you a Veteran?*

Yes

Please list all the household members who live with you:

Please list an Emergency Contact:

Name*

First Last

Phone*

Relationship*

Please list any health problems or disabilities (especially if receiving SSDI) to which we should be alerted:*

Please describe the top priority for work you would like done on your home:*

What is your average monthly household income*?*

*Please attach proof of homeownership (monthly mortgage statement or deed) and documentation of the income of each member of your household for the immediately preceding 12 months, e.g., paystubs, pension, Social Security, Social Security Disability Income (SSDI), Supplemental Security Income (SSI) payments. This information should include yourself and all other household members.

Please Attached Document PDFs

Max. file size: 100 MB.

Please read the following paragraph, then sign and date this application.

My signature indicates that I understand that LITTLE ACTS of LOVE work crew members are volunteers, and that the work done on the homes is done by teenage students under adult supervision and adult volunteers. I understand that their work may not be of professional quality, and that LITTLE ACTS of LOVE may not be able to complete all the work I am requesting. I also understand that my house may or may not be selected for work. In addition, if my house is selected, I hereby agree to hold LITTLE ACTS of LOVE, its board of directors, its staff and its affiliated organizations, harmless of and from any and all liability of whatever nature may arise out of or result from their work. Furthermore, I understand that my stated income and all information above are accurate, and if I provide fraudulent information, LITTLE ACTS of LOVE has the right to deny services to my household.

Full Name*

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Apply for Assistance Today

Homeowners who meet the following qualifications are eligible to apply.

Age 60 or older or have a physical disability.

Own and live in the home in need of repair.

You live in Berks County.

Your total household income was at or below 150% of the current FEDERAL POVERTY GUIDELINES for the previous 12 months.

To apply for home repairs please complete and submit the form below.