It’sabouttheliveswetouchwiththe work we do. Remodeling isa powerful toolforchange. Thisishowweimpactthe people around us.”–Bill Markt, CR

Dear Potential Client,

WelcometoReFIT! Formanymembersofourcommunity,limitedmobilitycreatesobstaclestoliving independently. Thepathtothefrontdoormaysuddenlyorovertimebecomeanarduousjourney,one that cannot be made without assistance. For the people we serve, having a resource to meet these simple, practicalneeds can make the differencebetween remainingindependentandhavingtoseekcareinan assisted living facility or adult foster home.

ReFITisuniqueinthatitutilizestheskillsandresourcesoftheconstruction industry to make homes accessible and safe. Wehavethespecialskillsandresourcestotackletheproblemsofaccessibilityinexisting homes. Awiderangeofprojectsispossible,suchasbuildingramps,wideningdoorsandmakingother extensiveimprovements. Eachprojectistailoredtothegoalofenablingourclientstoliveindependently in their homes.

ThankyouforyourinterestinReFIT. PleasecompletetheHomeownerQualificationFormandthe

Income Screening Formincluded with this letter. If you have any questions please feel free to call us at 503-698-8382.

Thank you,

ReFIT Project Committee

PO Box8358Portland, OR, 97207503 698-8382

What is the Application Process?

HowdoIknowifIqualifyforReFIT’sservices?

ThefirststepinapplyingforourassistanceistofilloutaHomeowner Qualification FormandsendittoPO Box8353,Portland,OR97207.Youmaygetaformfromyourcaseworkeroryoumaycallusat(503)698-

8382.Ifitisfound that yourapplication meetsallthecriteria,youwillreceiveacallfromamemberoftheAssessmentCommitteetoscheduleasitechecktoreviewyour needsandassessyour disability.Afterthesite checktheAssessment CommitteewillmakearecommendationtotheProject Committee.Iftherecommendation isinyour favorandtheProject CommitteevotestoacceptyourapplicationwewillforwardyourapplicationtoourBoard of Directors for approval. Then the Project Committee searches for a contractor that fits the needs of the client. We will then scheduleanothersitechecktodevelopaconstructionplan. Afterthesitecheck,the committeereportsbacktotheBoardwithitsfindingsandrecommendations andasecondreviewbytheBoard willdeterminewhethertheprojectqualifiesforReFIT'sassistance.

WhatqualifiesmeforpossibleassistancefromReFIT?

  • Homeowner or family member living in home must have limited mobility and/or functional limitation.
  • Thehomeownerorfamilymemberisabletostayinhomeasa resultof modification.
  • Therequestedmodificationsmustincreasetheaccessibilityofthehome.
  • Homecannotbea mobilehome,traileror modularhome, with the exception of ramps.
  • Withtheexceptionofthehouseandautomobilestheassetsofallhouseholdmembersmustnot exceed$20,000.00.
  • No plans to sell the home in the next 2 years.

Amongpotentialclientswhomeetthese minimumqualifications,toppriority isgiven tothose whodemonstrate thegreatestneed.Priorityclients mayhaveloworverylowincome,livealone, haveanemergencysituation,or beinimminentriskofinstitutionalization. Inaddition,thescreeningprocesstargetsclientswhohavethebest chanceofreapinglong-termbenefitsfromhomemodifications.Indicatorsofsuccessincludeclientswhoare alertandcooperative,havestablehealthoratreatablechronicdisease.

ProjectManagement

Onceaprojectisapproved, our Projects Managerensuresthattheneedsoftheclientaremetwithquality workperformedina timelyfashion.

Theprojectmanagementprocessisdesignedtoensurethatprojectsarecompleted ontime,withinbudget,and thatallworkisperformed according toindustrystandards. Coupledwiththescreeningandevaluation process, thisapproachensuresthatcompletedprojectsarereasonablesolutionstorealneeds.

POBox8353

Portland,OR97207

Phone503698-8382

Homeowner Qualification Form

Please complete to the best of your ability.

Name:

(Last)(First)Middle)

Address:

(Street)(County(City)(State)(Zip)

E-mailaddress

Phone:

DateofBirth:

Pleaseanswerthefollowingquestions.Allinformationwillbekeptconfidential.

1. / Doyouownandliveinthishome? / Yeso / Noo
Ifno,doyoulivewithafamilymemberwhoownsthishome? / Yeso / Noo

NumberLivinginHousehold______

How long have you lived in this home?______

2. / Isthishouseamobilehome,trailerormodularhome?
(Acceptable for ramps only) / Yeso / Noo
3. / Are you a Veteran? / Yeso / Noo

4.Excludingyourhomeandoneautomobiledoyour household remainingassetsexceed$20,000.00?

Yeso Noo

5.Doyouhaveapermanentphysicaldisability? Yes oNoo

If yes, pleasedescribe in as much detail as possible: ______

6.Doyouqualifyforanyotherprograms?YesoNoo

If yes, pleaselist:

7.CaseManager: Phonenumber:

(If you have one)

8. How did you hear about ReFIT, Remodeling for Independence Together?

Please briefly describe as specifically as possible, the work that you are requesting we perform and howit would improve your activities of daily living.(please attach additional sheet if necessary)

______

______

______

______

______

______

My signature below indicates that the information provided is accurate and complete. I give ReFIT

permission to come into my home for the purpose ofassessing my needs and disability and evaluating the scope of the work to be done.

X

Signature of homeownerDate

By initialing here I give my permission to share this information with other agencies that may be able to provide me with assistance. Please initial here

Note: The selection of your home into the program depends on many factors, including, but not limited to: applicant’s elderly or disabled status, income level, urgency of modifications needed, the number of applications received and the availability of ReFit resources.

Name ofperson submitting this referral otherthan homeowner:

For any questions please call our office at (503) 698-8382.

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  • We do not discriminate on the basis of color, national origin, religion, gender, age, marital status, sexual orientation, disability or any other basis prohibited by law.
  • ReFIT may use grant money to complete your project. Some grants come with conditions for use designed to prevent grant funds from being used for purposes that are unwanted by the grant source. For example, some grants may require compliance with the USA Patriot Act and Executive Order 13224, so that grant funds cannot be used in support of terrorism or a terrorist organization. You authorize ReFIT to run applicable searches or obtain additional information from you to determine if you meet the requirements of particular grants whose funds may be used to complete your project.
  • We also request that any selected applicant for our program adhere to the same non-discrimination policy when in contact with any of our volunteers, staff or anyone acting on behalf of ReFIT.

HOUSEHOLD INCOME & EXPENSE SCREENING

NAME(S): / PHONE: / EMAIL ADDRESS:
ADDRESS: / CITY: / STATE: / ZIP:
MAILING ADDRESS (IF DIFFERENT) / CITY: / STATE: / ZIP:

INCOME & ASSETS: (Please list everyone in the household)

Household Members: / Male or Female / Date of Birth / Source of Income (Salaries, Spousal Support, Child Support, Interest, Dividends, Pensions, Annuities, Insurance Disability, Social Security, Trust Funds, etc.) / Monthly Amount: / Most Current Income Tax Adjusted Gross Income: / Total Assets – Excluding Home & One Automobile (Cash in Banks, Cash Value of Life Insurance, 401K, IRA, Annuities, Stocks & Bonds, Automobiles, Recreational Vehicles, Boats, Other Watercraft, Personal Property)

Documents Used to Provide Verification: Please include a copy of the front page of your most recent tax return or 6 months statements for all bank and brokerage accounts. Please black out your social security number.

EXPENSES:

Monthly Expense: / Monthly Amount: / Current (Yes/No) / Extenuating Circumstances/Comments
Mortgage
Utilities (Power, Gas, Water, Sewer, Trash, Cable, Other)
Health Insurance/Medical Costs / N/A
Auto Expense (Loan, Ins., etc.) / N/A
Personal Loans / N/A
Credit Cards / N/A
Spousal Support / N/A
Child Support / N/A
Other (Please Describe) / N/A
Other (Please Describe) / N/A
Other (Please Describe) / N/A

I (we) certify that the above information is true and correct.

Signature:______Date:______

Signature:______Date:______

I understandthat ReFIT exists for the purpose of helping me to remain living in my own home in a safe and accessible environment. I acknowledge their efforts are not for the purpose of remodelingmy home for resale. Pleaseinitial here: ______

I currently do not have any plans to sell my homewithin the next 2 years unless medical conditions make it necessary to do so.

Pleaseinitial here:

I agree that I will cooperate with theProject Manager and Volunteer Team andthat I will assure that all ablebodied members of my familyparticipate in the rehabilitation effort in some way.

Please initial here: ______

I understand the Project Manager and the Volunteer Team are volunteering their time and it is likely that work will be performed on weekends and outside of normal business hours. I consent to work being performed on weekends, holidays, and in the evening hours Monday through Thursday. I understand that failure to allow work to be performed during these times could cause me to be disqualified from program assistance.

Please initial here:

I agree to notify a representative of ReFIT at 503-698-8382 immediately upon learning of any circumstance that would affect myfinancialcondition as listed above, and understand that any change could affect my eligibility for program assistance.

Please initial here:

I certify that the above informationis trueand correct; I further declare that the sum of my household assets do not exceed $20,000 over and above my residence and one vehicle.

Applicant’s Signature:

Date:

ReFIT Approval:

Pleaserememberthatthepurposeofourorganizationistoenhancethehomeowners’abilitytofunction wellinhisorher activitiesofdailyliving,inasafeandaccessibleenvironment,enablingthemtoremainintheirhome.

Our Program is not intended to prepare a home for resale.

Please mail to: PO Box 8353 Portland OR 97207

Fax: 866-680-2689

Email:

_____Accepted _____Denied If denied, state reason ______