3. Are you disabled? Yes _____ No ______

4. Besides your home, do you own other real estate? _______________________________

5. Are you (applicant) a female head of household? ( ) YES ( ) NO

6. Are you a grandparent raising a grandchild? ( ) YES ( ) NO

7. Is any member of your household handicapped? If yes, explain:_____________________

__________________________________________________________________________

8. Do you own, or are buying the home you live in? _______ If no, please stop here.

II. Home Information

1. My home is a (please circle)

Condo / Townhouse / House / Mobile / Home / R/V

2. Is your home within the Tucson City limits? Yes / No

3. What is the approximate age of your home? _____________ Year built? ___________

4. How long have you lived in this home? _________ Years

5. What is the full cash value of your home based on your tax statement? _______________

6. How many bedrooms are in your home? _________

7. How many bathrooms are in your home? _________

III. Rehabilitation Information

Please briefly describe the type of home repair you home needs. It is important to describe your repair and/or disability modification needs in great detail. Please number your three (3) most important repair needs first. Priority will be given to health and safety hazards. You may attach additional pages if you need more space to describe you repair needs.

#____ LEAKING ROOF OR ROOF REPLACEMENT - Describe your roof: include age, type, size, where it is leaking, for how long it has been leaking and any resulting damage.

#____ GAS LEAK - Is there a leak between gas meter and any appliances? Is gas disconnected by utility?

#____ ELECTRICAL – Are any outlets not working? Is the electric box broken? Is electricity disconnected?

#____ WATER LEAK – Is there a leak between water meter and any fixtures? Is water disconnected?

#____ STRUCTURAL - Is any portion of the home, (ceilings, walls, floors or attached structures) damaged?

#____ DISABILITY MODIFICATIONS –Do you need grab bars, a wheelchair ramp, a roll-in-shower, etc? (Medical documentation will be required if you are selected)

#____ SEWER LINE – Is there a leak between fixtures and the point of disposal? Is the sewer blocked?

#____ REPLACEMENT OF EXISTING FURNACE OR COOLING SYSTEM – How old is your unit? What type of unit is it? Is it broken? (Unserviceable refrigeration unit may be replaced with evaporative cooler, unless documentation can be provided that air conditioning is required for medical reasons.)

#____ EXISTING WATER HEATER REPLACEMENT – How old is the water heater? Is it broken? Does the home have hot water?

#____ SPECIAL CONDITIONS - All other emergencies threatening the life or health of the occupants not covered above will be considered on a case-by-case basis.

Please feel free to attach any additional information that may be helpful such as estimates, photos, etc. There is no guarantee that photos can be returned.

I certify that I have reviewed the information given on this form and that all information regarding family composition, income and assets is accurate and complete to the best of my knowledge. I understand that providing false statements and/or information is grounds for termination of this application.

_________________________________ _____________

Applicant signature / Date

If you have questions, please contact
Chuck Phelan at 322-9557 or write TMM Family Services, Inc.
3127 E. Adams Street, Tucson, AZ 85716

TMM Family Services, Inc.
REHABILITATION ELIGIBILITY GUIDELINES
PROGRAM SPECIFICATIONS

Income Guidelines

• All potential clients must have gross annual income equal to or less than the following:
  

The income guidelines are:

Note: For families larger than 6 persons, income guidelines are available upon request.

Home Parameters & Eligibility

• The home must be located within Tucson City limits.
• The home must be owner-occupied.
• The repairs may include structural and roof repairs, as well as correction of health and safety hazards such as ruptured water, sewer and gas lines. Disability modifications such as construction of ramps and installation of grab bars may also be done.
• The home must be free and clear of any judgments as evidenced by title search.
• Proof of Homeowners Insurance must be in place and the property cannot be in a flood plain.
• The owner(s) must be current with the mortgage (if applicable).
• Taxes should be current.

Home Inspection

• Licensed and certified building inspectors, in consultation with TMM staff & the homeowners, will determine what repairs to make.
• Licensed and certified inspectors are priority under this Rehabilitation assistance program.

Equal Housing Opportunity

Fees

• $25.00 application fee which allows TMM to pre-qualify rehabilitation clients