Fillable Adopt A- Neighbor Outreach Application (CITY OF HOPEWELL)

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Adopt A- Neighbor Outreach Application (CITY OF HOPEWELL)

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300 N. Main Street, Room 321, Hopewell, VA 23860
(804) 541-2220 ~ (804) 541-2318 fax ~ AdoptANeighbor@hopewellva.gov
Adopt-A-Neighbor Outreach Program
Department of Neighborhood Assistance and Planning
Applicant Information
Name of Applicant: ______________________________________________ Date: ______________
Address: ___________________________________________________________________________
Phone: ( ) _______________________ Email Address: _______________________________
Date of Birth: ________________________ Marital Status: ☐ Single ☐ Married
Are you the property owner? ☐ Yes ☐ No How long have you owned the property? ___________
Are You Disabled: ☐ Yes ☐ No Disability: __________________________________
Name of Spouse: ____________________________________________________________________
Date of Birth: ________________________
Disabled: ☐ Yes ☐ No Disability: __________________________________
Additional Households Members:
Name
Relationship
Date of Birth
Total Number of Individuals Residing in the Household: ____________________________________
Total Annual Household Income:
☐ Under $15,000 ☐ $15,000 - $19,000 ☐ $20,000 – $24,999
☐ $25,000 – $29,999 ☐ $30,000-$34,999 ☐ $35,000 – $39,999
☐ $40,000 +
Other Assistance Received (Food stamps, REAP, etc.): ____________________________________
Family Resource Information
Do you have any family members that live within 20 miles of Hopewell? ☐ Yes ☐ No
If so, who please list their names and contact information below.
Name
Relationship
Phone Number
Date of Birth
Type of Assistance Needed
Provide a statement of the type of assistance that is needed by your household.
I, the below signed, certify that the information provided on this application is true and correct to the best
of my knowledge and belief. I understand that this release discharges the City of Hopewell from any
liability or claim that I may have against the City of Hopewell with respect to any damage or injury,
personal or otherwise, that may result from this project, whether caused by the acts or omissions of the
City of Hopewell or its officers, directors, employees, or agents or otherwise. I also understand that the
City of Hopewell does not assume any responsibility for or obligation to provide financial assistance or
other assistance, including but not limited to medical, health, or disability insurance in the event of injury
or illness.
______________________________________________________________________________
Applicant Signature Date
NOTE: Approval of this application ONLY qualifies you for assistance, it does not guarantee that
assistance with be provided. If no individual or group volunteers to provide assistance the City is
NOT obligated to provide assistance.
For Staff Use Only:
Received By: __________________ _____________ Date: __________________
Reviewed By: _______________________________ Date: __________________
Approved: ☐ Yes ☐ No
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Adopt A- Neighbor Outreach Application (CITY OF HOPEWELL)

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Completed 14 July 2020

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