HANDS ON HOUSING SURVEY
Please read over the following questions below and circle your answer accordingly. These questions will help
us determine whether or not you are a good fit for this program. It is important that you consider each question
carefully and answer honestly.
1. Which of the following best describes your home? (circle your answer)
house
condominium
duplex
manufactured or mobile home
2. Is your home located within the full-purpose city limits of Austin?
Y
N
3. Do you rent, own, or mortgage your home? (circle your answer)
4. Do you own property other than the home on which you are requesting assistance?
Y
N
5. If you have an existing tax balance with Travis County, do you also have a deferral, payment plan, or
homestead exemption in place?
Y
N
n/a
6. Once work begins, can someone commit to being at the house for a solid period of 2-3 weeks to grant our
contractors access?
Y
N
7. Due to our high volume of home visits in a day, we may not always be able to schedule an appointment with
you before we come over. Are you comfortable with drop-in appointments from our staff and contractors?
Y
N
8. Are you in communication with your immediate family members about the work you wish to have done on
your home, and are they supportive?
9.
Y
Y
N
Are you willing to allow HoH staff, volunteers, and contractors to use your bathroom facilities?
N
10. Due to City code compliance regulations, we are often required to remove burglar bars: one per
bedroom and off (applicable) front or back door(s). Will this be an issue for you?
Y
N
11. If you have pets in the home, can you commit to confining them during the times our contractors and/
or volunteers are performing repairs on the house?
Y
N
n/a
12. Do you have an emergency contact that we may reach out to if we are not able to reach you for any
reason once work begins?
Name
Y
N
Relationship
Phone #
13. How did you find out about our program?
Homeowner Request for Services
Today’s Date
Applicant Name:
Address
Austin, TX
Home Phone
787
Cell Phone
Date of Birth:
Disabled?
Y
How long have you lived in your home?
N
Total Household Annual Income: $
yrs Do you have homeowners’ insurance? Y
Requested repairs:
1.
4.
2.
5.
3.
6.
Have any significant repairs been done recently? If so, please describe briefly, and indicate the
names of the agencies that assisted you:
Please list the names and ages of all occupants:
Can you and/or any family members/friends assist the team in making repairs?
Y
Signature
2921 E. 17th St. * Bldg. D* Suite 3 * Austin, TX 78702 * 512-386-9145 * www.interfaithtexas.org
N
N
Homeowner Consent & Release Form
The undersigned homeowner hereby requests and gives consent to Hands On Housing, a program of Interfaith Action of
Central Texas, a charitable corporation, to work on the property described below, and understands and agrees to the
following terms and conditions relating to work performed or materials furnished to the property and release of personal
information:
1. Hands on Housing has not made any representation, warranty or promise relating to the materials or workmanship.
Hands on Housing is primarily volunteer driven. We do not guarantee work to be done without imperfections as our
workers are not always professionals of the given field.
2. Hands on Housing expressly disclaims any expressed or implied warranty for our volunteer services, including any
warranty or fitness for a particular purpose, relating to the materials or workmanship.
3. Hands on Housing shall not refund, repair, replace or take any remedial action with respect to the materials or
workmanship.
4. The undersigned hereby releases and agrees to indemnify, defend and hold harmless Hands on Housing and Interfaith
Action of Central Texas from any and all claims or causes of action arising out of or relating to work performed or
materials furnished to the property.
5. The undersigned hereby authorizes Hands on Housing and Interfaith Action of Central Texas to release any personal
information for the purpose of soliciting volunteer support. The client’s personal information may be gathered from the
following two sources:
a.
His or her Hands on Housing application for assistance
b. From any home visit with the client by iACT employee or volunteer authorized by the Hands on Housing office. This
includes the use of photos.
6. The undersigned Client further authorizes iACT to use the Client’s image(s) or likeness of his/her image(s) to be
utilized in photography, website, videography, and promotional materials related to this and other community events.
7. The undersigned Client authorizes Hands on Housing/iACT to release information on the homeowner
Application to partner service organizations (Austin Area Urban League, Habitat for Humanity) and other
organizations that may be of help to you.
Name of Homeowner (1)
Last
First
Middle Initial
Last
First
Middle Initial
Name of Homeowner (2)
Address of Property
Austin, Texas 787
Street
Signature of Homeowner (1)
Date
Signature of Homeowner (2)
Date
2921 E. 17th St. * Bldg. D* Suite 3 * Austin, TX 78702 * 512-386-9145 * www.interfaithtexas.org