Free Reclamation Service
HOMEOWNER INFORMATION & AGREEMENT
Name of Homeowner: _____________________________________________________
Street address of home to be deconstructed: ____________________________________
Directions to home from nearest major landmark or street: ________________________
________________________________________________________________________
Mailing address if different from above address (for donation receipt):
________________________________________________________________________
Homeowner phone numbers: (primary) _______________ (alt.) ____________________
(e-mail): _____________________ (fax): _______________________
General Contractor:___________________________
(phone)_________________ E-mail__________________________________________
Restore relies upon unpaid volunteers to provide its reclamation service free of charge to homeowners. While our goal is to remove every item listed, we cannot guarantee that every item can be removed successfully within the allotted timeframe.
I own and agree to donate the following items. I understand that Bend Area Habitat for Humanity reserves the right to not remove any of these items for any reason.
________________________ ___________________________ ________
(Homeowner – printed name) (Reclamation Coordinator – printed name) (date)
_________________________ ___________________________ ________
(Homeowner – signature) (Reclamation Coordinator – signature) (date)
RECLAMATION CHECKLIST
(to be filled out by the Habitat Volunteer/Staff Member during site visit)
Proposed Date of Reclamation: ____________________________________________
ITEMS TO BE REMOVED:
Kitchen:
Appliances: (must be in working order)
Stove _____ Refrigerator _____ Dishwasher _____ Sink _____ Garbage_____
Disposal _____ Other: _____________________________________________
Cabinets:
Upper _____ Lower _____ Other Cabinets (describe location): ______________
_________________________________________________________________
Not to be removed:_______________________________________________________
Master Bathroom(s):
Sinks _____ Toilets _____ Vanities _____ Other: _________________________
Not to be removed:_______________________________________________________
Bathroom(1):
Sinks _____ Toilets _____ Vanities _____ Other: _________________________
Not to be removed:_______________________________________________________
Bathroom(powder room):
Sinks _____ Toilets _____ Vanities _____ Other: _________________________
Not to be removed:_______________________________________________________
Additional Items:
Carpeting (describe rooms for carpet removal): ___________________________
__________________________________________________________________
Exterior Doors _____ Interior Doors (must include door frame) _____
Windows (must be dual pane, vinyl or wood frame in good condition) _________
__________________________________________________________________
Garage Door(s) _____ Garage Door Opener(s) ______Lighting Fixtures _____
OTHER ITEMS: __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ITEMS NOT TO BE REMOVED:_____________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Direct Line: 541.815.2274 Store Line: 541.312.6709 Mailing: 740 NE 1st Bend OR 97701
CCB# 83516