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APPLICATION-2021-Repair-Affair

Sioux Empire Home Builders Care Foundation
2021 REPAIR AFFAIR DAYTM APPLICATION
EVENT WILL BE HELD ON TUESDAY, JUNE 8 (Date subject to change due to COVID-19 virus)
Repair Affair day allows volunteers to donate their time and expertise to someone in need. Since 1993, over 250 repair projects have been completed with 6,200+ man hours from volunteers. The focus of the event is to make homes more accessible for the elderly or permanently disabled.

HOMEOWNER INFORMATION Has the Repair Affair program helped you in the past? ...........................................................................YES ________ NO_______

NAME OF HOMEOWNER

STREET ADDRESS

CITY

HOME PHONE ( )

Female Male AGE

ST CELL PHONE ( )

ZIP CODE -

OCCUPANT INFORMATION TOTAL # OF PEOPLE LIVING IN THE HOME

YEAR HOME WAS BUILT

LIST ALL ADDITIONAL PEOPLE LIVING IN THE HOME If they bring in an income, their income verification documents are also required.

Name

Relationship

Age

Gender

Do they bring in an income?

___________________________ ________________________ ______________________ Female Male YES _____ NO _____

EMERGENCY CONTACT Living nearby

NAME

RELATIONSHIP

PRIMARY PHONE ( )

SECONDARY PHONE

( )

ETHNICITY Please check one as it's required by Dept of HUD - Will not be used to determine eligibility
Hispanic or Latino Not Hispanic or Latino

RACE Please check one
American Indian or Alaska Native Asian Black or African American Black or African American & White White Asian & White American Indian or Alaska Native & White American Indian or Alaska Native & Black or African American Other / More than one race

ELIGIBILITY QUESTIONS ***Please note that mobile homes will NOT be considered*** Do you own the home? Required for eligibility..................................................................................................YES ________ NO_______
If yes, is this your primary residence? Required for eligibility....................................................................YES ________ NO_______ Are you, or a dependent living with you full time, over the age of 65?................................................YES ________ NO_______ Are you, or a dependent living with you full time, permanently disabled?........................................YES ________ NO_______
If yes, please explain the disability_____________________________________________________________________ Will you be home June 8? Volunteers must be able to get into the home to make updates requested....................YES ________ NO_______ Will you be home June 15 if we have to postpone because of rain on June 8? ................................YES ________ NO_______

REPAIR REQUESTS Please check areas that you'd like the Repair Affair committee to consider as part of the repairs done to your home.

The committee and Community Development of Sioux Falls will determine improvements to be made.

DOOR OPENINGS Remove door steps Swing away hinges Remove thresholds Door closer Lower door view

BATHROOM Grab bars Change out faucet knobs with levers KITCHEN Replace cabinet knobs with loop type hardware Change out faucet knobs with levers WHEELCHAIR RAMPS Wheelchair ramp with landing Threshold ramp STAIRS Additional handrails on exterior of home Additional handrails on interior of home

Projects 100% not accepted: · Walk-in showers/tub revisions · Widening of doorways · Electrical work

DOOR HARDWARE Replace knobs with levers

· Lift chairs

OTHER Must be accessibility related: __________________________________________________________________________________________

Do you have yardwork you'd like help with? Volunteers may consider if additional time allows..................................YES ________ NO_______

HOW DID YOU HEAR ABOUT THIS EVENT? _______________________________________________________________

OFFICE Date Application Received _________________________ Mobile Home: Y N USE ONLY: Team Leader ____________________________________ Funding Source: HBCF CD

Owner?: Y N Project # ______

PAGE 1 OF 2

PROOF OF TOTAL HOUSEHOLD INCOME

APPLICATION IS DUE TO THE FOUNDATION'S OFFICE BY THURSDAY, APRIL 15, 2021 . No late applications will be accepted.
Mail completed application along with income verification forms listed below to:
Sioux Empire Home Builders Care Foundation Attn: Repair Affair Coordinator
6904 S. Lyncrest Place Sioux Falls, SD 57108

Documentation for all household income you are claiming below must be provided with this application before approval process can begin. (I.e. MOST RECENT income tax return, social security benefits statement or other official documents). Any occupant of the home that claims income must provide all income verification documentation.

All information will be kept confidential.

GROSS YEARLY TOTAL INCOME VERIFICATION

SOCIAL SECURITY Statement must be attached if including as income. . . . . . . . _______________________
SSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________________

(For office use only)
__________________________ __________________________

ANY PUBLIC ASSISTANCE . . . . . . . . . . . . . . . . . . . . . . . . _______________________ __________________________

SALARIES
W2 and two recent paystubs must be attached
if including as income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INTEREST & DIVIDENDS . . . . . . . . . . . . . . . . . . . . . . . . . .

_______________________ _______________________

__________________________ __________________________

PENSIONS & ANNUITIES . . . . . . . . . . . . . . . . . . . . . . . . . . _______________________ __________________________

ESTATE OR TRUST INCOME . . . . . . . . . . . . . . . . . . . . . . . _______________________ __________________________

RENTAL INCOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________________ __________________________

FARM / BUSINESS INCOME . . . . . . . . . . . . . . . . . . . . . . . _______________________ __________________________

YEARLY HOUSEHOLD TOTAL. . . . . . . . . . . . . . . . . _______________________
ONGOING MEDICAL EXPENSES . . . . . . . . . . . . . . . . . . . . . _______________________
Documentation is required. Please attach a doctor's statement, prescription or receipt. Ongoing medical expenses are defined as expenses that are incurred on a monthly basis (health insurance, maintenance medication, required monthly checkups). Occasional medicines, checkups or expenses are not to be included.

__________________________ __________________________
Verified by ___________ Date __________

AUTHORIZATION STATEMENT
Disclaimer of warranties and waivers will be sent upon approval of your project I am not presently planning, nor do I intend within the next three years, to sell my home. I understand and agree to have volunteers perform free accessibility improvements to my home. I am the owner of my home and it is my primary residency. The accessibility repairs I'd like done would benefit a person living in my home full-time. I understand that this information will be used by the Sioux Empire Home Builders Care Foundation to determine my/our eligibility for the Repair Affair program. I agree to have my home photographed for Repair Affair promotional purposes. I represent that this information is true and complete to the best of my knowledge and belief. I understand that any misrepresentation on the application will result in disqualification.
TWO SIGNATURES AND INCOME VERIFICATION DOCUMENTS ARE REQUIRED FOR ELIGIBILITY.

APPLICANT SIGNATURE REQUIRED FOR APPLICATION TO BE ELIGIBLE

DATE

CO-APPLICANT SIGNATURE 2ND SIGNATURE IS ALSO REQUIRED*

DATE

*If no other occupant - acquire the 2ND signature from relative, friend, neighbor, etc...application will be returned if 2ND signature is not filled out.

PAGE 2 OF 2

KEEP THIS PAGE FOR YOUR RECORDS

EVENT SPONSORED BY

REPAIR AFFAIR INFORMATION

DATE TUESDAY, JUNE 8 Subject to change based on weather that day. Rain day planned for June 15 only if needed.
ABOUT The event back began in 1993. The Repair Affair is a community service program that coordinates the efforts to make
FREE accessibility improvements for homeowners and/or dependent who are elderly and/or have a permanent physical disability with low income. It's designed for people who can't do the work themselves or afford to hire someone.
Homeowners needing major repairs done to their home are encouraged to contact the Housing Divisision of the City of Sioux Falls (605-367-8180) or other service organizations. The Repair Affair Coordinating Committee will attempt to match other applicants whose needs do not fit within the scope of Repair Affair with another appropriate agency.
PROJECTS All repairs must be only accessibility related.
ELIGIBLE PROJECTS: Wheelchair ramps, handrails, grab bars, etc... (see page 1)
PROJECTS NOT ELIGIBLE: Walk-in showers, widening doors, roof, siding, faulty issues to home due to lack of maintenance.
The Repair Affair committee and the Community Development of Sioux Falls will determine which homes meet the eligibility requirements and will have updates made. Funding and volunteer resources are limited so some projects may not be approved for this reason.
GUIDELINES Homeowners must meet certain financial guidelines. Ongoing medical expenses are to be deducted from the
applicant's income only if applicant is over the income limits. Proof of income (W2 tax form, or other official documents) will be required before the application will be processed. All projects are reviewed and selected by the Repair Affair Coordinating Committee.
FUNDING This program is funded by a block grant from Sioux Falls Community Development and funding from the Sioux
Empire Home Builders Care Foundation. The repairs are done at absolutely no cost to the homeowner.
TIME-FRAME The projects are completed on annual basis. All projects will be completed in one day (June 8) between
the hours of 8:00AM and 5:00PM. Extensive projects cannot be considered due to limited funds, time and volunteers.
THE DEADLINE FOR APPLICATIONS IS THURSDAY, APRIL 15, 2021.

ELIGIBILITY REQUIREMENTS Subject to change
· Your home must be within the following counties: Lincoln, Minnehaha, McCook or Turner · All projects must be accessibility-related - you, or a dependent living in the home full time, must have a permanent
physical disability OR be 65 years of age or older. If applying for dependent, doctor's note with medical conditions is required. · You must own and occupy the home - title of the property must be in your name · If your home needs major repairs or is not structurally sound, you will be referred to another appropriate agency · Work will not be done on mobile homes. No acceptions.

· Your COMBINED household income (minus ongoing medical expenses that are incurred on a monthly basis) must be within the following guidelines. *Income guidelines are provided by Department of HUD and are subject to change.

HOUSEHOLD SIZE 1 PERSON 2 PEOPLE 3 PEOPLE 4 PEOPLE 5 PEOPLE 6 PEOPLE 7 PEOPLE

ANNUAL INCOME* $48,300

$55,200

$62,100

$68,950

$74,500

$80,000

$85,500

PROGRAM FUNDING PROVIDED BY:

SIOUX EMPIRE HOME BUILDERS CARE FOUNDATION
PHONE: (605) 361-8322 FAX: (605) 361-8329 ADDRESS: 6904 S. Lyncrest Place Sioux Falls, SD 57108 EMAIL: info@hbasiouxempire.com HBACAREFOUNDATION.COM

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