Homeowner Application Form

Homeowner Name *
Homeowner Name
Homeowner Date of Birth *
Homeowner Date of Birth
Spouse Name (if applicable)
Spouse Name (if applicable)
Spouse Date of Birth (if applicable)
Spouse Date of Birth (if applicable)
Street Address *
Street Address
Home Phone: *
Home Phone:
Other Phone (optional)
Other Phone (optional)
Homeowner Eligibility *
Those aged 60 and older are eligible. Individuals younger than 60 with a permanent, physical disability are also eligible and must attach a physician’s statement defining the disability. Applications will not be processed without this statement.
If there are other adults living in the home besides you, are they able to help paint?
Include the following for all household members:
Verification may be requested by Metro Paint-A-Thon
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Has Paint-A-Thon painted your home before? *
Areas that need painting (select all the apply) *
Siding Type *
House
Garage
Trim Type *
House
Garage
Does your home currently have a violation or citation from the city? *
Demographic Information (optional)
This information does not affect applicant's eligibility. Check all that apply.
Homeowner Certification and E-Signature *
Homeowner Certification and E-Signature
I certify that the information in this application is true to the best of my knowledge and belief. I also certify that I do not plan or intend to sell my home within the next two years. I am aware that I will be charged for the cost of the paint and the time should the house be sold within two years from the date painted, unless it is determined that there are extenuating circumstances. I confirm that any physically able person(s) residing in my home or visiting for the project day will work alongside Paint-A-Thon volunteers. I also confirm that, except for conditions that may be described in this application, my home and the surrounding area is a safe place for volunteers. I understand that my home may be tested for the presence of lead-based paint by the Paint-A-Thon home inspector. I am aware that the Paint-A-Thon director may refer my application to a partner organization, if that group can more quickly and effectively care for my home, and that I will be notified in the event that happens. I understand that if my home is selected, photographs may be taken of me and/or my home, and these photographs may be used by the news media and/or in publications and materials to help promote Metro Paint-A-Thon and/or the Greater Minneapolis Council of Churches. I understand that the people who may work on my home are unpaid volunteers; that few (if any) of these volunteers are skilled in the building trades; and that Metro Paint-A-Thon and the Greater Minneapolis Council of Churches, make no warranties or representation, express or implied, about any of the material(s) used or work done by anyone on my house. I hereby release Metro Paint-A-Thon and the Greater Minneapolis Council of Churches, and all associated with it, from all liability arising from negligence for any personal injury or property damage arising out of or relating to the work done on my house. I further certify that I have, and will maintain, homeowner’s insurance.
Homeowner #2 (if applicable)
Homeowner #2 (if applicable)
Assistant to the Homeowner (if applicable)
Assistant to the Homeowner (if applicable)
Please complete if you are a non-homeowner assisting the homeowner in completing this application:
Date of Application *
Date of Application
Use 2-digit number for Month (MM) and Day (DD).Example: 01 for January, 09 for Day