Hammers of Hope is a program of:
HAMMERS OF HOPE APPLICATION
Cool Down 2016/AC for Seniors Program
Mission
Hammers of Hope is intended to be a safety net that provides home repairs,
focused on safety, increased independence, and greater accessibility issues to
low-income families, seniors, and persons with disabilities.
Dennis Murphy-Program Manger
[email protected]
Tom Rojas-Program Coordinator
[email protected]
AC for Seniors/Cool Down St. LouisJefferson County, Missouri Air
Conditioner Application
Dear Applicant,
3875 Plass Road, Bldg. A
Festus, MO 63028
Phone: Dennis Murphy 636-465-0983
x106
Phone: Tom Rojas 636-465-0983
x112
Fax: 636-465-0987
Website: www.hammersofhope.org
Each summer when funds are available, Hammers of Hope conducts two initiatives, AC for Seniors and Cool
Down-Jefferson County, Missouri, to give window air conditioning units to low income families, seniors, and
persons with disabilities to provide a safe place of heat relief in at least one room of their residence.
Hammers of Hope is a nonprofit volunteer program that brings volunteers and communities together to improve
the homes and lives of low-income homeowners. The mission of Hammers of Hope is to assist those who do
not have the means or ability to make home repairs themselves, particularly homeowners who are over the
age of 60 or individuals with disabilities. Applicants must currently live in Jefferson County, Missouri, and
only residents located within Jefferson County, Missouri are eligible to apply.
The attached application MUST be signed by the principle resident(s), completed and turned in with all
proof of income documents that apply to you and ALL those who live in your home. A check list of
documents needed has been provided.
Please understand that returning the application or a visit to your home by someone from Hammers of Hope
does NOT mean you will be accepted into the program. If you are selected to receive a window unit, volunteers
will deliver and install the unit for you. You must sign a “Hold Harmless Agreement” and once the unit is
installed it becomes your property.
HOH reserves the right of refusal should a project be determined to not fit our mission parameters.
Applicant’s home must be safe and healthy in order for our volunteers to enter to complete the installation of
the unit. Unfortunately not everyone who applies to the program will be able to get assistance due to a limited
number of units available. This letter list the income guidelines and provides a check list of documents that
MUST be returned with your application.
Incomplete applications and those returned without the required documents listed above, may disqualify you
for consideration for the AC units. You will be notified by letter whether if you have been selected by Hammers
of Hope to receive the AC unit.
As stated, to receive services, residents(s) must be willing to sign a “Hold Harmless Agreement”
protecting the partnering agencies and their volunteers from any cause of action, claim, loss, demand, or suit
arising from or related to: the presence of any Hammers of Hope Affiliate on or about the premises, any
services provided by any Hammers of Hope Affiliate; negligence or any damages to personal or real property;
or any injuries sustained by the homeowner, family members, or friends. This Hold Harmless Agreement
shall serve as a waiver that your story and any pictures taken can be used for fundraising, volunteer
recruitment and promotional purposes.
.
If you have any questions, call 636-465-0983, extension 106 or 112 and leave a detailed message.
Sincerely,
Dennis Murphy
Program Manager
A program of JCCP
Created 5-6-15 P:\Departments\CC-HOH\Applications
HAMMERS OF HOPE AC PROGRAM
Hammers of Hope is intended to be a safety net that provides home repairs; focused on safety, increased
independence, and greater accessibility issues. “Hammers of Hope” is a cooperative charitable effort made
possible by Jefferson County, Missouri. Jefferson County Community Partnership (JCCP) and a coalition
of home repair volunteers, contractors and agencies.
HOH would like to be able to help everyone who needs assistance but services are available based on
funds and volunteer availability.
ELIGIBILITY:
1. Applicants must live in Jefferson County, Missouri and meet the low-income guidelines below.
2. Applicants must provide proof of residency in Jefferson County, Missouri, Missouri.
3. Applicants must meet income eligibility guidelines and provide documentation of total household
income for all persons living in the home.
4. Seniors 60 and older, people with urgent medical needs and persons with disabilities shall be
deemed as priority cases.
5. Applicants must provide a copy of their state ID or driver’s license.
6. Applicants must provide a list of any agencies contacted who referred applicant to HOH or denied
you services.
Maximum Household Income Guidelines based on 130% of current HUD Jefferson County, Missouri Very Low
Income:
Family Size (Check one)
One Person
Two Persons
Three Persons
Four Persons
Five Persons
Six Persons
Seven Persons
Eight Persons
Annual Income (Check one)
$32,538
$37,158
$41,778
$45,398
$50,160
$53,856
$57,552
$61,248
Monthly Income
$2,711
$3,096
$3,481
$3,866
$4,180
$4,488
$4,796
$5,104
APPLICATION CHECKLIST
(please provide those items that apply to you and those who live with you):
All Benefit Letters should be dated within the last two (2) months.
Disability benefit letter
Circuit Breaker Form
SSI benefit letter
TANF benefits letter
Pension/Annuity benefit letter
Unemployment benefit letter
Veteran benefit letter
Child Support benefit letter
Food Stamp award letter
Most recent bank statements
Copy of Valid State ID or License
Rental Income Verification
 Interest/Dividends statements
Signed Application
Most Recent Payroll Stubs
No Income Affidavit
Copy of Federal/State Taxes (if filed)
AC for Seniors/Cool Down Jefferson County, Missouri 2016
Air Conditioner Application
SECTION A
3875 Plass Rd Bldg. A
Festus, MO 63028
Phone: Dennis Murphy 636-465-0983 x106
Phone: Tom Rojas 636-465-0983 x112
Fax: 636-465-0987
Website: www.hammersofhope.org
HOMEOWNER INFORMATION Please Print Clearly
Name(s) of Homeowners:
Mr. Mrs. Ms.: _______________________________________________
Address: _______________________________________
City: _________________________________ Zip Code:____________
Home Phone: ________________________________________
Cell Phone: __________________________________________
Work Phone: _________________________________________
Email: ______________________________________________
Emergency Contact Name: ______________________________
Emergency Contact Number: ____________________________
Office use-date received
___________________
Approved ___________
Denied _____________
Referred____________
Case #______________
Please check ethnicity:
White African-American
Hispanic
Native-American Asian
Other: _______________
Veteran: No Yes
Spouse of Veteran
Branch: ________________
Rank:__________________
Dates of Service: __________
Estimated value of the home: $
Age of Home:
How long have you lived in home? _________
Is the home your principal residence Yes No
Is Home Rented? Yes No
Total Number of people living in the home?__________ (list names below)
Have you ever applied to Hammers of Hope? Yes No
Has Hammers of Hope ever done work/provide services for you? Yes No If yes, what year(s) ________
How did you hear about the program? Disability Resource Association Mideast Area Agency on Aging
Jefferson/Franklin Community Action Corp. 211 St. Vincent DePaul Elected Official Flyer
Radio/Newspaper Website Social Worker Friend/Relative Neighbor Facebook
Other:_______________________
List the names and current age of ALL people living in the home, including applicant
(attach list if more space is needed):
Full Name
Date of Birth
Relation to
Gender
List all disabilities
Homeowner
1.
2.
3
4.
5.
6.
7.
8.
Homeowner
SECTION B
PROVIDE INCOME FOR ALL HOUSEOLD MEMBERS
IF ANY MEMBER OF THE HOUSEHOLD 18 YEARS OR OLDER DOES NOT RECEIVE ANY INCOME
OR BENEFITS MUST COMPLETE THE NO INCOME AFFIDAVIT.
ENEFITS THEY MUST COMPLETE THE NO INCOME AFFIDAVIT
YOU MUST PROVIDE COPIES FOR ALL DOCUMENTS LISTED BELOW THAT APPLY TO YOU.
Monthly GROSS
Income Amounts
(before taxes)
Your Name
Name
Name
Name
Name
Name
Employment
Wages
Social Security
Disability/SS
Pension/Annuities
Unemployment
Rental Income
Child Support
Food Stamps
Unemployment
Other Income
Total Gross
Monthly Income
List the amount of EACH PERSON'S ASSETS. If you do not have a certain asset, write "N/A."
Checking
Account
Savings Account
Certificate of
Deposit
IRA/Mutual
Funds/Stock
Acceptable Documents:
Benefit letter dated within last 2 months for: Social Security, Disability, SSI, Pension/Annuities, Veteran
Benefits, Child Support, Food Stamps and Unemployment.
2 most recent Payroll Stubs.
Full Bank Statements for all accounts for last 2 months.
IF all income documents are not enclosed, your application cannot be processed.
Section C HOUSE INFORMATION
Check the one that applies:
I live in a standard residence
I live in a
I live in an apartment
List other agencies contacted who referred you to us or denied you services: Put an ( R ) for referral and a (D) for denial
1. ___________________________________ 2. ___________________________________
I understand this application is to receive a window air conditioner only?
 Yes
 No
General Release Form: I/we hereby authorize Hammers of Hope or its designated agents to obtain and receive all records and
information pertaining to eligibility for the rehabilitation program, including employment, income (including IRS returns), credit,
banking information, and residency and from all persons, companies, or firms holding or having access to such information.
Hammers of Hope or its designated agents have the option to release this information for the purposes of volunteer education. This
authorization, shown as original signature or photocopy, hereby gives Hammers of Hope the right to request all information it can
or could obtain from any person, company or firm on any matter referred to above. I/we agree to have no claim for defamation,
violation of privacy, or otherwise, against any person or firm or corporation by reason of any statement or information released by
them to the Hammers of Hope for the purposes of the program. The term of this authorization shall commence on the date of
signature(s) and be in force for a period of five (5) years.
My signature below indicates that the information provided herein is accurate and complete. I have read the information provided
by Hammers of Hope and have a basic understanding of the program and its process. I give Hammers of Hope with volunteers my
permission to inspect my home for purposes of house selection and/or repair. I would like my information shared with other
agencies that might be able to help me.
I certify that all the information in this application is true and complete. I understand that any misrepresentation of
information or failure to disclose information requested on this form may disqualify me from participation in the
program(s), and may be grounds for termination of assistance and civil penalties.
Applicant Signature: __________________________________________ Date:_________________
Applicant Signature: __________________________________________ Date:_________________
RETURN APPLICATION and PROOF OF INCOME DOCUMENTS TO:
Hammers of Hope
3875 Plass Road, Bldg. A
Festus, MO 63028
Questions? Call 636-465-0983 ext. 112 and leave a detailed message or email: [email protected]
Homeowner Hold Harmless Agreement: (HOH reserves the right of refusal should a project be
determined to not fit our mission parameters.)
I affirm that in consideration of the work to be performed free of charge by Hammers of Hope, a charitable effort
coordinated by Jefferson County Community Partnership and community volunteers on and about the premises (as
defined herein), I, as the owner/resident of the premises and the beneficiary of the air conditioning unit installed
thereon, for myself, my heirs, assigns, executors, and administrators, hereby release and hold harmless Hammers of
Hope, a charitable effort coordinated by Jefferson County Community Partnership and its affiliates, officers, directors,
employees, agents and volunteers (collectively “Hammers of Hope Affiliates”) from any cause of action, claim, loss,
demand, or suit arising from or related to:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
the presence of any Hammers of Hope Affiliate on or about the premises;
any services provided by any Hammers of Hope Affiliate;
the negligence of any Hammers of Hope Affiliate;
any damages to personal or real property; or
any injuries sustained by myself, any of my family members, or any of my invitees.
I also agree to have any pictures taken of me or my project to be used for promotional purposes.
I agree to accept the work performed by Hammers of Hope in an “AS IS” condition.
I authorize the completion of this work and the presence of Hammers of Hope Affiliates on the premises of
this purpose.
Signature of Applicant: ______________________________________________________ Date: _________________________
Signature of Witness: ______________________________________________________ Date: _________________________
NO INCOME AFFIDAVIT
PLEASE COMPLETE THIS FORM ONLY IF ANY MEMBER OF THE HOUSEHOLD 18
YEARS OR OLDER DOES NOT RECEIVE ANY INCOME OR BENEFITS.
Case Number
I:
(Name of person claiming no income)
do swear that I am 18 years of age or older and do not have any income or receive any benefits
at the time I/or a household member applied for the Hammers of Hope Program.
I am signing this form to declare that I currently do not have any income from any source. My
financial support comes from (please describe):
I
I understand that by completing, signing, and dating this form, I declare I have no household
income and that the information I am providing is correct. I understand that providing false
information may result in denial of services and civil penalties.
Signature:
Date:
Hammers of Hope is a program of: