Untitled document

Thank you for visiting the site of Rebuilding Together OKC! 

To qualify you must:

  • Be at least 55 years of age.
  • Live in the greater OKC area (between County Line on the west and Post Road on the east, and Danforth on the north and South 89th on the south.) 
  • Be living in the home and your name must be on the title.  We will not work on rental or leased property.

By submitting this application you agree to the following:

I certify that the information provided above is true and complete to the best of my knowledge.  I have read the information provided by Rebuilding Together OKC and have a basic understanding of the program, its process and the qualifications I must meet to participate.  I give Rebuilding Together OKC volunteers my permission to inspect my home for purposes of project selection and/or repair. I also grant Rebuilding Together OKC permission to take or have taken photographs and film, including television, of my home.  I consent and authorize Rebuilding Together OKC, its advertising agencies, news media and any other persons interested in Rebuilding Together OKC and its work to use and reproduce the photographs and films and to circulate and publicize the same by all means including, without limiting the generality of the foregoing, newspapers, television media, brochures, pamphlets, instructional materials, books and clinical material for the primary purpose of promoting and aiding its programs and its work. 

* - Required field.
*First name
Middle name
*Last name
Mailing Address 1
Mailing Address 2
Mailing City
Mailing State
Mailing Zip code
Physical Address 1
Physical Address 2
Physical City
Physical State
Physical Zip code
Home phone
Work phone
Work phone ext.
Cell phone
E-mail address
County
Ethnicity
Detailed Ethnicity
Gender
Date of birth
If you are not the homeowner filling out this application, enter information here.

Otherwise, enter emergency contact.
Name
Relationship
Address
City
State
Zip code
Home phone
Work phone
Work phone ext.
Cell phone
Application date
General Areas ADA
Appliances
Carpentry
Concrete
Doors
Electrical
Energy
Exterior Paint
Flooring
Furnace
Grab Bars/Handrails
Gutters
Hot Water Heater
Locks
Other
Plumbing
Roof
Ramp
Safety
Stairway/Porch
Trash Removal
Tub/Tile
Wall Repair/Paint
Windows
Yard Work

Comments:
Previous Recipient
Year:
Best Time To Call
Other Contact Name
Other Contact Relationship
Other Contact Phone
Other Contact Email
Hear About
Age
Are you employed?
Is the head of household a grandparent?
Disabilities
Please indicate any special needs:
Household Monthly Gross Income
Income
AnnualIncome
Monthly Mortgage Payment
Head of Household
Assistance Received SSI
SSDI
Food Stamps
VA Benefits
AFDC
Medicare
Medicaid
Home and Community Based Services
Caseworker Name
Caseworker Phone
Single or Joint Checking and Savings Account Balance
IRA, 401(k), or similar Account Balance
CD Balance
Stock and Bond Value
Own Other Property (besides the home you live in)?
Receive Rent on Other Property?
Residents Living in Household (including head of household)
Name Relationship Age SSN Employed Disabled Gender Ethnicity Detailed Ethnicity Veteran
Residents Pay Rent?
If yes, how much?
Any Residents have Disabilities?
Please indicate any special needs:
Number of Pets
What kind?
Own your Home or have Tenancy for Life Agreement?
Years in Home
Homeowners Insurance?
If no, please explain. If yes, include Insurance Company & policy number:
Priority Board
Current Taxes Paid?
How will these repairs/modifications be important to you or help you or your care giver?
Something About Yourself...
Any Family Members Help with Repairs?
If no, why not?
In & Out Shower with Ease
Get to Bathroom Easily
On & Off Toilet with Ease
Smoke/Fire/Monoxide Detectors
Veteran?
Signed Consent