ScottsdaleAZ.Gov

1. Accepts the service or assistance “as is” and will be personally responsible for making any changes or improvements.
2. Be aware that some projects might not be completed, or may be cancelled or rescheduled due to insufficient manpower, equipment, weather conditions, etc.
3. Observe the work crew if physically able.
4. Be on site while work is being performed or will provide notice to Project Coordinator.
5. Will keep all pets away from the work crew.
6. There will be no use of alcohol or any illegal substance on the day of the project.

Failure to observe this agreement will be grounds for cancellation of service.

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Head of Household Information Date: Head of Household Name: Date of Birth: (mm/dd/yy) Are you receiving Social Security benefits? YES NO Are you receiving disability benefits? YES NO Spouse Information Spouse's Name: Spouse's Date of Birth: (mm/dd/yy) Are you receiving Social Security benefits? YES NO Are you receiving disability benefits? YES NO Address and Phone Number Information Complete Address: Home Phone Number:  Enter a valid phone number. Example: 123-456-7890 Alternate Phone Number:  Enter a valid phone number. Example: 123-456-7890 My home is a: House Mobile/Manufactured Home Multi-tenant facility Patio Home Townhome/Condo How long have you lived in this home? Provide the total number of persons living in your home including yourself: OneTwoThreeFourFiveSixSevenEightMore than eight Please list their names, date of birth and relationship to you: (only those that are over 18 years old) 1. Name, date of birth and relationship to you: 2. Name, date of birth and relationship to you: 3. Name, date of birth and relationship to you: 4. Name, date of birth and relationship to you: Approximate combined annual gross income (before taxes) of ALL persons living in this home: Up to $37,200Between $37,201-$42,500Between $42,501-$47,800Between $47,801-$53,100Between $53,101-$57,350Between $57,351-$61,600Between $61,601-$65,850Between $65,851-$70,100 Do you operate a business out of this home? If YES, please provide business name and business license number. YES NO Business Name: Business License Number: Is your home in foreclosure? YES NO Did you receive a Notice of Violation from Code Enforcement? YES NO If YES, who is your Inspector? Eric AllenMario AlvarezPaul AndersonSita BargeDavid DiazJerry ElizaldeJorge EspinozaDavid LauerMichael RitterS.R. SmithRick ValenzuelaAlyssa Yanez Do you own other real estate property? YES NO If YES, please list properties below: Property #1: Property #2: Property #3: Please describe what you are seeking assistance for: I have read through this application and certify that all information provided is true and correct both written and verbal, to the best of my abilities. I understand any fraudulent statements or information provided will be grounds for cancellation and I will be unable to request assistance from this program in the future. APPLICANT: YES CO-APPLICANT: YES How did you hear about the program?