Essential Home Repair Application NameStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePhoneEmail AddressCountySelect a countyCulpeperFauquierMadisonOrangeRappahannockDemographicThis information is completely forHead of Household?YesNoPlease indicate your genderMaleFemaleDo any household members have a disability?YesNoHave you served in the Military?YesNoEthnicityHispanicNon-HispanicThis is for statistical purposes onlyRaceWhiteBlack/African AmericanAsianOtherThis is for statistical purposes onlyMonthly IncomeVerification for all income is requiredEmploymentChecking AccountPensionSavings AccountSocial SecurityStocks/BondsPersonal PropertyOther than homeChild SupportOther SourcesMonthly Living ExpensesMortgageUtilitiesFoodOtherHousehold MembersPlease provide the following information for all household membersNameRelationshipDisabledYesSexMaleFemaleAnnual IncomeSource of IncomeDescribe Repairs NeededHow did you hear about Foothills Housing CorporationSharing with our partnersYesNoIf your application is a more appropriate fit with other, similar programs may we share it with them? Unless you give us permission to share your information with other organizations, your application will be kept confidential. If you check yes, you give Foothills Housing Corporation your consent to share the information you provide on this application with similar organizations.Photo Consent *If Foothills Housing Corporation selects your house to be repaired, pictures of your home may be taken.PhotosIf Foothills Housing Corporation selects your house to be repaired, pictures of your home may be takenSignatureStart signing your signature hereYour browser does not support e-Signature field.I certify that the information provided is true and correct. I understand that if I have knowingly given false or misleading information in the completion of this application, I can be denied services. I hereby authorize the release of information in support of the above.Emergency Home Repair Program Authorization and ReleaseSignatureStart signing your signature hereYour browser does not support e-Signature field.The undersigned hereby certifies that he/she is the owner of the property located at the above address and authorizes Foothills Housing Corporation to facilitate repairs and improvements as necessary and as funds are available to the property. The owner hereby releases indemnity and agrees to hold harmless Foothills Housing Corporation and its staff from any liability in conjunction with the performance of the repairs and improvements. Owner agrees to provide Foothills Housing Corporation access to the property at reasonable times for the purpose of inspecting the work. Owner certifies that he/she intends to occupy the property for at least one (1) year after the date the work is completed. Owner agrees that the quality of the installation of the materials cannot be guaranteed beyond a period of one (1) year. Owner understands that he/she may request information as to the specific work to be done to the property prior to signing this authorization and release, and agree to the work to be performed as determined by Foothills Housing Corporation.Send MessageSave as DraftPlease do not fill in this field.