BRI Paint-A-Thon Application Return completed application to:

2250 Eaton Street – Garden Level, Denver, CO 80214 Phone: (720) 339-5864 Fax: (303) 274-1314-

www.brothersredevelopment.org

Since 1978, Brothers Redevelopment has used the Paint-A-Thon to paint homes for more than 7,250 senior citizen or disabled homeowners.

You qualify if:-You are 60 years of age or older, are physically disabled, or both -You own and occupy your home -You liveon a limited income and cannot a�ord to hire a painting contractor -You cannont physically paint your home -Your home is in significant need of exterior painting -Your home is less than 20ft in height -The job can be �nished by a group of volunteers in one day -You agree to be present on the day of painting to engage withvolunteers -You have no plans to sell your home or move for at least two years

TELL US ABOUT YOUR HOUSE:1. What year was your home built? ____________ 2. Is your home? One story One-and-a-half stories (tri-level)3. What part needs painting? Trim only Entire house Detached Garage Shed 5. Is other work needed? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________*All Paint is high quality exterior paint donated by Diamond Vogel Paints

TELL US ABOUT YOURSELF:Name_______________________________________ Address: _____________________________________City_________________________________ Zip _____________ County____________________________Phone Number_________________________________ Email_______________________________________ Age______ Gender____________ Widow/Widower ________ Number of years lived in your home________ Are you or your spouse a military meteran? Yes No Branch Served_________________________Check All Applicable Boxes: Respiratory Issues Nervous System Issues Stroke Back Problems Diabetes Chronic Pain Hearing Impaired Cancer High Blood Pressure Arthritis Mobility Problems Multiple Sclerosis Vision Impaired Other Medical:___________________________

INCOME INFORMATION:Please check the boxes of all income types that your receive. Copies of income documentation required*. Social Security Income (Include most recent annual statement of benefits) Social Security Disability Income (Include most recent annual statement of benefits) 1099 Form from pension or retirement provider (Include most recent annual statement of benefits) Any other income received (Include documentation) Statement of Housold Income Demographics Form (Completed page #3 of this application)

TOTAL MONTHLY HOUSEHOLD INCOME: $_________________________

List the monthly dollar amounts of your recurring medical expenses:_____________________________________________________________________________________________________________________________

*This information is required, but held in strict con�dence. Any sensitive information, such as account numbers, social security number, etc. may be blotted out at your discretion. PAGE 1

Have you received services or referrals from Brothers Redevelopment in the past? Yes No Do you have family, friends or a community group who can help paint? Yes No

*I understand that my family members who are able are required to help volunteers with painting. Adult children or grandchildren who are able to help but refuse will be asked to not be present during painting. How did you hear about the Paint-A-Thon? TV Newspaper Internet Family Friend Neighbor Colorado Housing Connects Non-profit referral Please list other (be specific):__________________________________________________________________

Please Complete the Following Survey:1. I feel connected with my community (For example; Neighbors, Local Organizations, and Non-pro�ts) ____Strongly Agree ____Agree ____Neutral ____Disagree ____Strongly Disagree2. The outside of my home causes me stress. (For example; lowering neighborhood property values, eyesore to your neighbors, home deterioration, lack of ability to pay for repairs and paint) ____Strongly Agree ____Agree ____Neutral ____Disagree ____Strongly Disagree3. I feel con�dent that I can age well in my home. (For example; your house will meet your needs and you will meet the needs of your house for the foreseeable future) ____Strongly Agree ____Agree ____Neutral ____Disagree ____Strongly Disagree4. My house adds to the beauty of my neighborhood. (For example; you are proud of the way your house looks) ____Strongly Agree ____Agree ____Neutral ____Disagree ____Strongly Disagree5. I am a contributing member of my community. (For example; you have positive relationships with your neighbors and members of your local organizations) ____Strongly Agree ____Agree ____Neutral ____Disagree ____Strongly Disagree *To the best of my knowledge, this information is correct. I agree to indemnify and hold harmless thesponsoring companies, agencies, or volunteer from and against any and all claims, damages, actions,liabilities, judgements, and expenses. By my signature below, I give my consent to photographs, videos,and potential TV or newspaper interviews as related to my volunteer painting project.

Signature: _________________________________________________________ Date:__________________

*INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

(Please cut at line and retain the section below for your records)

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PAINT-A-THON PROCESS: Approval: 1. Complete Paint-A-Thon application and send to Brothers Redevelopment 2250 Eaton St, Garden Level, Suite B. Denver, CO 80214 2. If you application is approved, Brothers sta� will contact you to schedule an estimate at your home. 3. During the estimate Brothers sta� will insure that your home meets program requirements, test the exterior paint to see if it contains lead, identify other exterior work needed. Con�rm your color choice, take pictures of your home, and �ll out a estimate form. 4. If your home is approved after the estimate, Brothers sta� will have all of your information and work to pair your project up with a volunteer team the right size and skill level.Scheduling: 1. Brothers sta� will contact you with a date which volunteers would like to paint. When you con�rm your availability, the project is formally scheduled. 2. If your house has lead-based paint, Brothers sta� will need to contain the chipping and �aking paint before your volunteer project date. You will be contacted to schedule a time for this containment.Paint-A-Thon Project Day: 1. You are required to be home on the day of your Paint-A-Thon project. Volunteers will need to use your restroom and access to your tap drinking water. 2. If you have family members who plan to help with the project, they need to be working. If you have family that is unable to help with the project, please do not have them to your house on the date. PAGE 2

STATEMENT OF HOUSEHOLD INCOME/DEMOGRAPHICS

The Department of Housing and Urban Development – Community Development Bl ock Grant funds have been awarded to fund Brothers Redevelopment's Paint-A-Thon program. Federal regul ations require the program to provide bene�t to low and moderate-income persons. All questions on this document must be completed. The form must be acknowledged and signed.

1. Name of person completing form: ____________________________________________________________

2. Head of Household Name___________________________________________________________________

3. Home Address: __________________________________________________________________________(address) (city) (state) (zip code)

4. Is the Head of Household:a. Female? ______Yes ______No b. Disabled ______Yes ______No

(A disability is a physical or mental impairment that substantially limits one or more of the major life activities ofsuch individual; a record of such an impairment; or being regarded as having such an impairment.)

c. Age 62 years or older? ______Yes ________No

5. Total annual household income: $____________ (Income applies to all adults 18 years or older living in household)

6. Total Number of Persons in Household: _______

7. Number of household members being served by program: ______ Name of Program: Paint-A-Thon

8. For each household member served by the program, please answer both a and b, placing the number ofhousehold members that meet the criteria of the category in the blanks or column. Note that this informationis required for reporting purposes.a. Ethnicity: Hispanic or Latino ________ Not Hispanic or Latino ________ b. Race: (Please add # of household members in appropriate box(es) below)

SINGLE RACE CATEGORY MULTI-RACE CATEGORYWhite American Indian/Alaska Native & White Black/African American Asian & White Asian Black/African American & White American Indian/Alaska Native American Indian/Alaska Native & Black / African American Native Hawaiian/Other Paci�c Islander Other Multi-race (Please explain)

THIS INFORMATION WILL BE USED FOR NO OTHER PURPOSE THAN TO DETERMINE AND VERIFY INCOME ELIGIBILITY AND WILL BE HELD STRICTLY CONFIDENTIAL

I hereby 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 veri�cation by the City and County of Denver 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. 3729, 3802])

______________________________________________________________________________Signature Date

* * * * * * * * * * * * * * * * * * * * * * For Office Use Only * * * * * * * * * * * * * * * * * * * * * * * * * *

Number of Persons Present and Receiving Information: ________________

Median Income Level: _____ _____ _____ _____ _________________________ _____________ 30% 50% 80% 80%+ Reviewer Date

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