I hereby certify that…
- I own and occupy the home described in the application that follows or am showing written permission from my landlord to modify my home.
- The information contained herein is complete and true to the best of my knowledge.
- This information is provided to qualify me for help from Community Housing Coalition. The program is intended to assist low-income homeowners with special needs in correcting substandard housing conditions which pose an imminent threat to their life or safety; or in performing accessibility modifications or other repairs necessary to allow a homeowner facing displacement to remain in his or her own home safely.
- I give permission for CHC personnel to access information to verify the contents of this application and to facilitate the repair of my home.
- I understand that CHC is not required to correct all deficiencies in my home nor make the home conform to any local, state, or housing quality standards.
Indemnification and Release
The Community Housing Coalition of Madison County (CHC) utilizes and coordinates churches, volunteer groups, participating agencies and organizations to work on housing rehabilitation projects.
- I am aware that many of the repairs for CHC are provided by volunteers.
- I agree in this covenant to indemnify, protect and hold harmless CHC and this organization’s agents,
employees, Board of Directors as well as participating churches, organizations and agencies. This includes church members, trustees, elders, clergy, employees and agents of CHC members who may be associated with CHC on the project from any and all losses, damages, claims, liabilities, suits, actions, judgments, cost and attorney fees arising out of any activity directly or indirectly related to the repair project being done at my home.
- This release is effective for me, my personal representative, assigns and heirs.
- I know that if I become injured while trying to assist CHC and its representatives that I am responsible for all related healthcare expenses.
- I assume full responsibility for any and all claim costs, including my own, arising directly or indirectly out of activities, acts or omissions by volunteers working with CHC.
- I certify that these statements are true and correct, and have been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest, and I release CHC from any liability whatsoever for supplying such information.
- I furthermore give Community Housing Coalition of Madison County permission to photograph/video me, my family and this project and understand that these pictures/video(s) may be distributed to participating groups and may be used for publicity purposes.