Sometimes bad things happen to good people. We’re here to help. Contact us. Please fill out the form in its entirety and a representative will be in touch with you soon.

Candidate Information Form - Home Repair/ Need

Date *

YYYY

Family/ Person in need *

First Name

Last Name

Candidate must be a resident of one of the following Georgia Counties. Please select one: *

Applicant is a Greene County resident.

Applicant is a Putnam County resident.

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Referring Individual/Organization (If applicable)

Phone

(###)

###

####

Referring NHN Member (If applicable)

Phone

(###)

###

####

If URGENT, describe catastrophic or emergency event.

Specific Reason for Request *

Please be as detailed as possible about the specific home repair/need AND (if applicable) why you support this candidate's request. Recipient MUST own the home. Be as detailed as possible.

What has been done already to rectify the problem? *

Please provide total combined annual income of all household family members: *

Provide two references for this individual/family *

Please provide a full name and phone number for each.

Please select all that apply. Recipient is: *

Low-Income Family

Senior Citizen

Military Veteran

Victim of Domestic Violence

Special Needs

Other

If other, please explain.

Is this a specific one time and quality-of-life impacting need? *

Have all other available rsources (government, insurance, family, other organizations, etc.) been utilized? *

If yes, please explain.

Are there family/ friends who can contribute with funds, labor, or materials for the success of the project?

Please select all of the boxes below stating that you have read and understand the following: *

I understand that basic confirmation of financials will be provided and utilized as appropriate.

I understand that a background check may be required when appropriate.

I understand that the applicant demonstrates the need for a hand-up and not a hand-out.

I understand that a minimum of two reference checks is required.

I understand that Neighbors Helping Neighbors does not fund on-going expenses such as utility bills, repairs to rental properties or payments of loans.

Are there any other circumstances relative to your request that you would like NHN to consider? *

Recipient: By typing your name in the box below, you verify that the information submitted in this application is true and accurate to the best of your knowledge. *

Type Full Name Below

Referring Party (If applicable): By typing your name in the box below, you verify that the information submitted in this application is true and accurate to the best of your knowledge.

Type Full Name Below

Your request has been received. A member of our team will be in touch with you soon.

Thank you!

Neighbors Helping Neighbors