A Brush With Kindness Inquiry Form

The information below will be used to help determine if A Brush with Kindness is right for your exterior home repair needs. Please review the program description before completing this form. All personal information (name, address, phone) will be kept confidential.

Prospective Applicant Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Residence Information
What is the total number of people who live in your home?
How many are under 18?
Please describe the type of exterior work you are requesting for your home, being as specific as possible:*
How did you hear about A Brush With Kindness?
Documentation

Are you able to provide documentation that you meet the following requirements of A Brush with Kindness? (Do not provide documents at this time.)
Own this home (deed or current tax payment):
- Yes
- No
Up to date on all property taxes and mortgage (if any):
- Yes
- No
Have homeowner’s insurance coverage:
- Yes
- No
Total household annual income before taxes and deductions:
(include all sources of income for all adults in the home)
Credit is in good standing:
- Yes
- No

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A Brush With Kindness Inquiry Form

Prospective Applicant Information

Residence Information

Documentation