Greater Blessing Application – Fuller Center

Greater Blessing Application Form

We will use this completed application to determine your eligibility for a home repair known as a Fuller Greater Blessing project. If you are accepted, we at Fuller will do our very best to provide most if not all labor and services free of charge and to obtain the needed materials at the lowest prices possible. When your project is completed, you will have the greater blessing of giving back to another Salt Lake City homeowner in need by “paying forward” the actual expenses of your project in very small monthly amounts that you can afford until that total is “repaid.” All funds you pay forward will be used to repair a neighbor’s home, just as a previous family’s “payments” were used for your home’s repair—a great blessing for all involved. Please fill out the application completely (leave blank any sections that do not apply to you). We know this application can look a bit intimidating, but the great news is that gathering all this information will ultimately be of real help to you personally in organizing your finances, building a workable budget, and gaining financial peace and confidence. It will be worth the effort! You’ll no doubt be pulling together a lot of paperwork as you calculate your monthly income and expenses. Be sure to keep all those records. All information you have provided will be kept strictly confidential. If you need help filling out your Fuller Greater Blessing application or simply have questions about it, please feel free to contact Tara at 801.231.9146.

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Name *

First

Last

Date of Birth *

Current Age *

Home/Mobile Phone and Best Time to Reach *

Work Phone and Best Time to Reach *

Email *

Marital Status *

Married
Separated
Unmarried (Single, Divorced, Widowed)

Dependents and others who live with you (Not listed by Co-Applicant)

Name, Age, and Gender

Home Address *

Street, City, State, and Zipcode

Co- Applicant's Name (If Applicable)

First

Last

Date of Birth

Current Age

Home/Mobile Phone and Best Time to Reach

Work Phone and Best Time to Reach

Marital Status

Married
Separated
Unmarried (Single, Divorced, Widowed)

Dependents and others who live with you (Not listed by Applicant)

Name, Age, and Gender

Home Address

Street, City, State, and Zipcode

Do you own any other land or property? *

If yes, please list address(es):

State, City, State, and Zipcode

Please describe the repairs requested: *

Do you have homeowner's insurance? *

If yes, please list the provider and policy number: *

SOURCES OF MONTHLY INCOME: Employment Income (total net take-home pay for all household members after taxes & other withholdings) *

$ Amount/Month

AFDC/TANF

$ Amount/Month

Child Support You Receive

$ Amount/Month

Alimony You Receive

$ Amount/Month

SSI

$ Amount/Month

Social Security

$ Amount/Month

Unemployment Benefits

$ Amount/Month

Workman’s Comp

$ Amount/Month

Food Stamps

$ Amount/Month

WIC

$ Amount/Month

Rent Collected from Tenants

$ Amount/Month

General Assistance (disability payments, regular financial help you receive from family, etc.)

$ Amount/Month

Other Income (specify)

$ Amount/Month

TOTAL MONTHLY INCOME (add all above amounts) *

$ Amount/Month

MONTHLY EXPENSES (give monthly average if not fixed): Mortgage Payment

$ Amount/Month

2nd Mortgage Payment, if applicable

$ Amount/Month

Gas Bill

$ Amount/Month

Electric Bill

$ Amount/Month

Water, Sewer, Garbage Bill

$ Amount/Month

Groceries

$ Amount/Month

Food Away from Home (eating out)

$ Amount/Month

School Lunches

$ Amount/Month

Gasoline for Car(s)

$ Amount/Month

Car/Truck Payment(s)

$ Amount/Month

Car/Truck Insurance

$ Amount/Month

Car/Truck Maintenance

$ Amount/Month

Public Transportation

$ Amount/Month

Phone Bill (landline and mobile)

$ Amount/Month

Internet Service/Cable/TV

$ Amount/Month

HOA Payment

$ Amount/Month

Laundry/Dry Cleaning

$ Amount/Month

Doctor(s)/Hospital (list only what you pay out of pocket, including copays & deductibles)

$ Amount/Month

Prescriptions/Supplements/Other Medications (list only what you pay out of pocket, including copays & deductibles)

$ Amount/Month

Dentist/Orthodontist (list only what you pay out of pocket, including copays & deductibles)

$ Amount/Month

Clothing/Gifts/Holiday Expenses

$ Amount/Month

Home/Yard Maintenance

$ Amount/Month

Hobbies/Pets/Habits/Recreation

$ Amount/Month

Tuition

$ Amount/Month

Health Insurance

$ Amount/Month

Life Insurance/Other Insurance

$ Amount/Month

Homeowners Insurance (if payment is NOT included in mortgage payment)

$ Amount/Month

Business Liability Insurance (if you conduct a business in your home, including renting to tenants)

$ Amount/Month

Charitable/Religious Donations

$ Amount/Month

Child Care

$ Amount/Month

Credit Card Payment

$ Amount/Month

IRS (tax payments)

$ Amount/Month

Child Support/Alimony You Pay

$ Amount/Month

Savings

$ Amount/Month

Student Loan Payment

$ Amount/Month

Personal Loan Payments (payday loan, personal bank loan, etc.)

$ Amount/Month

Other Expenses/Debts (specify)

$ Amount/Month

TOTAL MONTHLY EXPENSES (add all amounts above) *

$ Amount/Month

Today's Date *

I understand that by filing this application, I am authorizing Fuller Center for Housing of Salt Lake to evaluate my actual need for repairs to my home. I own my home, and it is my intent to live in that home for at least the next 5 years as evidence of my willingness to be a partner family. I understand that the evaluation will include personal visits. I have answered all the questions on this application truthfully. I understand that if I have not answered the questions truthfully, my application may be denied. By signing, I further agree to allow Fuller Center for Housing of Salt Lake to use the fact that my home is being repaired to increase awareness of their mission; photographs, videos, and other media may be taken and used to promote Fuller Center’s mission. I have read this agreement and understand that my application and all additional required documentation will be securely maintained in the Fuller Center for Housing of Salt Lake files whether or not I am approved for a Greater Blessing project at this time. I understand that information contained in the application packet will be kept in utmost confidence and not shared with any other person or organization outside the Fuller Center for Housing of Salt Lake. I acknowledge that I have read and understand the details of the Authorization, Release, and the Privacy Agreement.

Applicant's Initials *

Co-Applicant's Initials