Safe At Home El Dorado County home safety services



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Safe At Home El Dorado County

HOME SAFETY SERVICES

Our mission is to preserve and revitalize homes and communities, to assure that low-income homeowners, particularly those who are elderly, disabled, and families with children, live in comfort, safety and independence.

To apply for services, please submit the following:





  • Gross Income Verification Documents for each household member

(include as attachments)

Note that in many cases, all of your income can be shown in a single document or two. For example, a bank statement showing the income direct deposit or a copy of the award letter from the Social Security Administration.

Examples of income verification documents are:


Please black out social security numbers and account numbers.

INCOMPLETE APPLICATIONS CANNOT BE CONSIDERED

Safe At Home El Dorado County

c/o Rebuilding Together Sacramento

P.O. Box 255584

Sacramento, CA 95825-5584

916-455-1880 Phone

916-731-7077 Fax

www.rebuildingtogethersacramento.org


FOR OFFICE USE ONLY


Date Received: _______________________________

Eligibility: SAH  CRA  RD  HEC 
Accept/Decline: _______________________________
Date Verified: __________Method:_______________


Safe At Home El Dorado County




HOME SAFETY SERVICES APPLICATION

Please check one:  Mr.  Mrs.  Ms. Today's date:__________________________________


Last Name: _______________________________________ First Name: __________________________________
Address: ____________________________________________ City: _____________________________________
Zip Code: ___________ Date of Birth: _______/_______/________ Home phone: (______) ___________________
Cell Phone (if avail.): ( _____)______________________ Email: __________________________________________
Referred by: Name: _______________________________________ Phone: (_____)________________________
Organization: ______________________________________________________________________
Are you a Veteran? _______________ Widow of a Veteran? _______________
Please list everyone who lives in the house (use additional sheets if necessary):

Name Age Relationship Employed?


_________________________________ _____________ ___________________ Yes No

_________________________________ _____________ ___________________ Yes No

_________________________________ _____________ ___________________ Yes No
In case of an emergency - or to assist us in contacting you, please list two (2) personal contacts:

Name Relationship Phone

_____________________________________ _________________________________ ____________________


_____________________________________ _________________________________ ____________________


PROPERTY INFORMATION


Do you own this home? Yes No If "Yes," what YEAR did you purchase the home? _______________

In what YEAR was this home built? ______________ Is this a mobile home? Yes No

Do you have a renter(s)? Yes No If "Yes," what do you receive in rent? $_____________/month?

If "Yes," what is your renter’s income? $_____________/month?


autoshape 24

ETHNICITY Please CIRCLE one. This information is required by our funders.

African Amer./Black Asian/Pacific Islander Caucasian/White Hispanic/Latino Native American

Other: Non-Hispanic _________________________________
Rebuilding Together will not deny any services to people on the grounds of ethnicity, color, religion, national origin, gender or personal lifestyle.


INCOME

How many people live in your home? Include income from all people living in the home.

Pautoshape 26lease CIRCLE the total number of persons living in the home AND the total household income range.

Number of Persons in Household

Very Low Income

Low Income

Low & Moderate Income

1

$0 - $15,050

$15,051 - $25,050

$25,051 - $40,050

2

$0 - $17,200

$17,201 - $28,600

$28,601 - $45,800

3

$0 - $20,090

$20,091 - $32,200

$32,201 - $51,500

4

$0 - $24,250

$24,251 - $35,750

$35,751 - $57,200

5

$0 - $28,410

$28,411 - $38,650

$38,651 - $61,800

6

$0 - $32,570

$32,571 - $41,500

$41,501 - $66,400


Amount of Gross Income Source of Income (for example, SSI, pension, wages, etc.)

$_________________________/year _____________________________________________

$_________________________/year _____________________________________________

$_________________________/year _____________________________________________


Total Gross Income $_________________________/year


NEEDS ASSESSMENT

Safety/Accessibility/Disabilities: YES NO

Do you use a wheelchair?







Do you use a walker?







Can you get in and out of the tub/shower with ease?







Can you navigate steps easily?







Can you get on and off the toilet with ease?







Do you have a mat in the bath/shower?







Can you rise from a sitting position easily?






Do you have any disabilities we should be aware of ? Please list: _________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________
How many smoke/fire detectors are there in your home? ________________
How many carbon monoxide detectors are there in your home? ____________

Home Safety Needs - List your top three safety modification needs:

1.


2.


3


I/We certify that the above information is true and correct to the best of my/our knowledge. I/We realize that failure to provide all information requested could result in our application being invalid. I/We authorize you to check any references necessary to complete the processing of this application for the purpose of receiving housing rehabilitation and repairs through Rebuilding Together. I/We also understand that any information received will be kept confidential and will be used strictly for determining my/our eligibility for this program.
Signature(s) of Homeowner(s)



Date

Date


PLEASE MAIL OR FAX APPLICATION including Income Verification Documents to:

Safe At Home El Dorado County

c/o Rebuilding Together Sacramento

P.O. Box 255584

Sacramento, CA 95825-5584

FAX: (916) 731-7077

Telephone: (916) 455-1880

julieo@rebuildingtogethersacramento.org
Did you remember to include

Application (3 Pages)

Income Verification Documents

Copy of Discharge Papers (for veteran applicants only)



We will contact you by telephone within 4-8 weeks after we review your application.





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