Paint-A-Thon Homeowner Application

Since 1978, Brothers Redevelopment has used the Paint-A-Thon to paint homes for more than 7,800 older adult homeowners or homeowners
living with a disability.

You can qualify if:

You are 60 years of age or older
Are physically disabled
You own and occupy your home
You are on a limited income and cannot afford to hire a painting contractor
Your home needs painting
Your home is less than 20ft in height
The job can be finished by a group of volunteers in one day
You will be present on the day of painting
You plan to live in your home for at least two years

You can fill out the online form below, OR you can download the pdf and mail it to us.

Download Homeowner Paint-A-Thon Application

"*" indicates required fields

Household Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

County*

Phone*

Email*

Date of Birth*

Month

Day

Year

Gender

Ethnicity*

*Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic” or“Latino.” **Not Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Hispanic or Latino

Non Hispanic or Latino

Race:
(Please add # of household members in appropriate box(es) below) (Note: This information is for Federal Data Collection reporting only and not for determination for assistance)

Single Race Category (# in Household)
Enter below

American Indian/Alaska Native

Asian

Black/African American

Native Hawaiian or Other Pacific Islander

White

Multi-Race Category (# in Household)
Enter below

American Indian/Alaska Native & White

Asian & White

Black/African American & White

American Indian/Alaska Native & Black/African American

Other Multi-race

How many adults (18+) in household?*

How many minors in household?*

Total # in Household*

Female Head of Household*

Yes

Does anyone in the household identify as disabled?*

Yes

Armed Service Veteran?*

Yourself or a household member

Yes

Who is an Armed Service Veteran?*

Yourself

Family Member

Branch served*

Number of years lived in your home*

Is the Head of Household age 62+?*

Yes

What year was your home built?*

Income Information

Income

Please check the boxes of all income types that you receive. Copies of income documentation REQUIRED*

Social Security Income

Social Security Disability Income

1099 Form from pension or retirement provider

Any other income received

Income documents

Include most recent annual statement of benefits for Social Security Income, Social Security Disability Income, 1099 pension or retirement provider;
Provide documentation for any other income received;

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 128 MB, Max. files: 15.

Total Monthly Income*

This information is required, but held in strict confidence. Any sensitive information, such as account numbers, social security number, etc. may be blotted out at your discretion. Addition documents may be requested.

Homeowner Information

Tell Us About Yourself*

How did you hear about the Paint-A-Thon?*

Have you received services from Brothers Redevelopment in the Past?*

Yes

Survey

Read the statements and select the number that corresponds with your response.

I am proud of my home.

1 – Strongly Disagree

2 – Disagree

3 – Agree

4 – Strongly Agree

I feel connected to my community.

1 – Strongly Disagree

2 – Disagree

3 – Agree

4 – Strongly Agree

My family and I have the power to change our situation.

1 – Strongly Disagree

2 – Disagree

3 – Agree

4 – Strongly Agree

I spend time with my neighbors.

1 – Strongly Disagree

2 – Disagree

3 – Agree

4 – Strongly Agree

I am confident I can age well in my home.

1 – Strongly Disagree

2 – Disagree

3 – Agree

4 – Strongly Agree

My home adds to the beauty of the neighborhood.

1 – Strongly Disagree

2 – Disagree

3 – Agree

4 – Strongly Agree

I herby certify that, to the best of my knowledge, the above information is complete and correct. I understand that the information I have provided is subject to verification by the local City, County and HUD. (Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. [18 U.S.C 1001,1010.1012;13 U.S.C.37293802]) I agree to indemnify and hold harmless the sponsoring companies, agencies or volunteers from and against any and all claims, damages, actions, liabilities, judgements and expenses.

Signature*

Write your signature in the box. Use the mouse on a desktop or your finger on a phone.

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.