Hole in One for Habitat Oakland

Friday, June 16th @ the Links at Crystal Lake, Pontiac

7:30 am Sign-in & Continental Breakfast

9:00 am Shotgun Scramble Start

Longest Drive Women & Men
Closest to Pin Women & Men
$5000 Cash Hole in One
Dixon Golf Challenges
Skins Game
Raffle Prizes at Dinner

800 Golf Drive, Pontiac, MI www.tlacl.com

Proper Golf Attire (No Jeans, T-shirts, or Gym Shorts) The Links is a Spike-less Facility

Raffle Donations

Please consider donating a prize to the raffle! Gift Cards of any style or denomination, tickets to local sporting or concert events, sports memorabilia and golf related items appreciated. Donors recognized during the event.

Donation Contacts

Bob Struck, 248-674-3937, bob@cpmoving.com or Chris Van Gordon, 248-310-1785, chrisv@habitatoakland.org

Critical Home Repair Application

Contact Information

Name

First Name Last Name

Address

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Armed Forces Service(Required)

If so, which branch of Military?

Household Information

How long have you lived in your home?

Type of Home

Single Family

Duplex

Condo

Mobile Home

How many adults, 18 years or older, live in your household?(Required)

Adults

How many children, 17 years or younger, live in your household?(Required)

children

Household Disability Status (optional)

One or more household members has a disability

N/A

Do you have accessibility needs, interior or exterior, that are not being met? (installation of grab bars, widened doorways, wheelchair ramp, etc.)

Yes

If so, please describe the need below:

Are you a DTE Customer?

Yes

If so, was your refrigerator built prior to 2003?

Yes

How did you hear about Habitat Oakland?(Required)

If Habitat Homeowner or previous Rock the Block participant, please state Referring Homeowner Name below:

I would like to receive updates from Habitat Oakland

Yes

Program Eligibility

Please answer the questions below to provide Habitat with information about your current housing status, ability to pay for repair services and your willingness to partner with our organization.

Homeownership (Check All that Apply)(Required)

I am the legal owner of my home (my name is listed on the property deed)

I am NOT the homeowner; I am currently renting the home

I have a land contract

This home is my primary residence

I am current on my mortgage or current on a payment plan for delinquent payments

I am current on my property taxes or current on a payment plan for delinquent taxes

I am current with my homeowner's insurance policy

If you are the legal owner, what date did you purchase your home?

If you are renting, you may still be eligible for some services however you would need consent from your landlord. Please provide their information below and Habitat will contact them if necessary.

Landlord Name and Landlord Phone or Email

Ability to Pay (Check All that Apply)(Required)

I understand that Habitat will charge a reasonable fee for the services I am approved for

My fee will be reviewed with me and agreed upon prior to project approval

My fee is due and shall be paid in full prior to the work day on my home

If my project is approved, I will be charged an additional program administrative fee of $10

Willingness to Partner (Check All that Apply)(Required)

I am willing to complete the required number of sweat equity hours for my home repair within the organization

I am willing to display partnership materials (lawn sign, stencil)

Critical Home Repair Service Available

This program focuses on exterior home repairs that will be completed by certified contractors. Included in this program is a FREE energy audit from the Consumers Energy Helping Neighbors Program for qualified households. A technician will come to your home to perform energy tests to help identify ways to reduce your energy costs. Some people are eligible for free energy upgrades. For more information about this FREE service, visit: consumershelpingneighbors.com. You will automatically be referred to this program. Below is a list of services available. Homeowners financially contribute to the completion of their project by paying a fee for services. The fee is determined by HFHOC staff after a home assessment has been completed.

My home is in NEED of one or more of the following services

Energy Audit to identify savings

Replace/repair home roof

Repair/replace porch and steps

Install wheelchair ramp

Other

Please type another option here

If Energy Audit, what is your Consumers Energy account number?

Financial Information

Please select the sources of income for all members of your household. Ex: Job, Social Security, Child Support, etc. Please list the amounts BEFORE taxes.

Income Source #1

Income Source #1, How Often Are You Paid?

Income Source #1, Amount Per Check

Income Source #2

Income Source #2, How Often Are You Paid?

Income Source #2, Amount Per Check

Income Source #3

Income Source #3, How Often Are You Paid?

Income Source #3, Amount Per Check

Income Source #4

Income Source #4, How Often Are You Paid?

Income Source #4, Amount Per Check

Authorization & Release* I understand that by submitting this application form, I am authorizing Habitat for Humanity of Oakland County (HFHOC) to evaluate my eligibility for home preservation services which includes a criminal background, sexual offender check, verification of homeownership and property tax status. I have answered all the questions on this form truthfully. The original or a copy of this form will be retained by HFHOC even if the application is not approved. HFHOC will only share the information on this application form with outside agencies offering services that I may be eligible for (such as OLHSA, Faith in Action and DTE Energy) and as needed to provide preservation services I select and are part of the program such as Consumers Energy.(Required)

I agree

I understand that:

Completion of this form and initial site assessment does not guarantee that I receive repair services.

Habitat must deem home in acceptable condition for requested work to be performed and those that do not will not be completed.

Please Fill Out Your Name as a Signature(Required)

Information for Government Monitoring Purposes

The following information is requested by the federal government for housing programs in order to monitor the organizations compliance with fair housing law. You are not required to furnish this information, but are encouraged to do so. The law provides that an organization may neither discriminate on the basis of this information, nor on whether you choose to furnish it or not. However, if you choose not to furnish it, under federal regulations this organization is required to note race and sex on the basis of visual observation or surname.

If you do not wish to furnish the information below, please check the box below.

I do NOT wish to furnish this information

What race do you identify with?

If Other, Please Specify Race/National Origin

Do you consider yourself Hispanic, Latino, Latina, or of Spanish Origin?

What gender do you identify with?

If Other, Please Specify Gender Identity

I have read Habitat for Humanity of Oakland County's Privacy Policy

I agree

Privacy Policy

NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about housing programs, please talk to a Habitat representative about arranging alternative accommodations.

Habitat for Humanity of Oakland County (HFHOC) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared orally and/or in writing will be managed within ethical and legal considerations. Additionally, we want you to understand how we use the personal information we collect about you. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information.

What is nonpublic, personal information?
Information that identifies an individual personally and is not otherwise publically available information, such as your Social Security Number or demographic data such as your race and ethnicity
Includes personal financial information such as credit history, income, employment history, financial assets, bank account information and financial debts
What personal information does HFHOC collect about you?
We collect personal information about you from the following sources:

Information that you provide on applications, forms, email, or verbally
Information about your transactions with us, our affiliates, or others
Information we receive from your creditors or employment references
Credit Reports
What categories of information do we disclose and to whom?
We may disclose the following personal information to financial service providers (such as companies providing home mortgages), Federal, State, and nonprofit partners for program review, monitoring, auditing, research, and/or oversight purposes, and/or any other pre-authorized individual and/or organization. The types of information we disclose are as follows:

Information you provide on applications/forms or other forms of This information may include your name, address, Social Security Number, employer, occupation, account numbers, assets, expenses, and income.
Information about your transactions with us, our affiliates, or others; such as your account balance, monthly payment, payment history, and method of
Information we receive from a consumer credit reporting agency; such as your credit bureau reports, your credit and payment history, your credit scores, and/or your
We do not sell or rent your personal information to any outside entity.
We may share anonymous, aggregated case file information; but this information may not be disclosed in a manner that would personally identify you in any This is done in order to evaluate our program, gather valuable research information, and/or design future programs.
We may also disclose personal information about you to third parties as permitted by law.
How is your personal information secured?
We restrict access to your nonpublic personal information to HFHOC employees who need to know that information in order to perform their housing counseling duties. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information; and we train our staff to safeguard client information and prevent unauthorized access, disclosure, or use.

Opting Out of Certain Disclosures
You may direct HFHOC to not disclose your nonpublic personal information to third parties (other than disclosures made to project partners and those permitted by law). However, if you choose to opt out, we will not be able to answer any questions from your creditors, which may limit HFHOC’s ability to provide services such as foreclosure prevention counseling.

If you choose to opt-out, please click the button below to print the form, sign and return this form to the Habitat Oakland Office at 150 Osmun St. Pontiac, MI 48342.
Download the Form

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