Online Assistance Application

This form will submit your application. The application will be signed upon meeting in person.

Warning!! It is a Federal crime punishable by fine and/or imprisonment, to knowingly make false statements concerning any of the above facts as applicable under the provisions of Title 18, US Code, Section 1014.


Applicant’s Statement

I certify that I do not have the financial means (savings, investments, etc.) to perform the repairs for which I am applying. I certify that the above statements are true, accurate, and complete to the best of my knowledge and belief. This application shall remain the property of Rebuilding Together, to which it is submitted for the purpose of obtaining assistance.

I hereby consent to and authorize Rebuilding Together, after giving reasonable notice, to enter the property for the purpose of determining the need and scope of the repair(s) specified above. I authorize the disclosure of the above information to only those persons or agencies as necessary to secure the assistance for which this application is submitted.