JOSHUA Homeowner’s Application 2017

Urban Mission, 301 North 5th Street, Steubenville, OH 43952

Phone: 740-282-8010 Fax: 740-282-8514 Website: www.urbanmission.org

Name: ______Phone: (____) ______

Street: ______Date of Birth: ______

City: ______State: ______Zip: ______

Marital Status (circle one) Married Widowed Single Divorced

Do you have any health problems to which we should be alerted? Yes No

If yes please explain: ______

______

Please specify your means of income: Wages Pension Social Security

Other

If other, explain: ______Please attach proof of income with application

Please list all the dependents that live with you (list additional dependents on the back)

Name

/

Age

/ Relationship to Homeowner /

Income

Please describe the top two priorities for work you would like done on your house:

(We do not replace furnaces, roofs, windows or vinyl siding.)

1.  ______

2.  ______

Do you own your home? ______Are you purchasing on a land contract? ______

(A copy of your deed or other proof of ownership must accompany this application!)

Do you carry liability insurance on this property? Yes No

Do you rent out any portion of this property? Yes No (If yes, you must attach a monthly rent record, renters agreement, etc.)

Why are you applying for assistance?

______

Have you ever applied to the JOSHUA program? ______If so what year? ______

Have you ever received help from JOSHUA before? ______If so when and what was done? ______

How did you hear about the JOSHUA Program? ______

______

If filled out by someone other than the Homeowner, please provide the following information:

Name: ______Phone: (_____) ______

Address: ______Relationship to Owner:______

City: ______State: ______Zip: ______

The owner understands that the work done on homes is performed by volunteers who take part in the JOSHUA program, and that many of these volunteers are students under the age of 18. Work projects are selected based on the number of volunteers coming and their ability to complete certain projects. Selection is based on the discretion of the Urban Mission Staff. The owner also understands that his/her house may not be selected for work this summer. If the owner’s house is selected for work, the owner hereby agrees to release the Urban Mission Ministries, Inc. and its staff, volunteers, officers and directors from all liability for damage to the owner’s house and personal property, and the owner further agrees to indemnify the Urban Mission Ministries, Inc. and its staff, volunteers, officers and directors, and to hold them harmless from all liability in case of claim or suit arising from work done or other acts incidental to JOSHUA project work on the owner’s house as described herein.

Signature: ______Date: ______

Application Checklist:

q  Did you complete all information requested?

q  Have you enclosed proof of ownership?

q  Have you enclosed proof of income?

Applications will not be processed without proof of ownership and income attached to this application!! All applications will need turned in no later then May 1, 2013.

Please Note: Work will not begin until the beginning of June 2017!!

Urban Mission JOSHUA Program

“Journeys Of Service Helping Upper Appalachia”