Rake My Home!

Please complete the form below to apply to have your home cleaned. Please know, this is only part 1 of the 2 part process to have your home cleaned. Once, an application is received we will contact you to set-up a time to evaluate your home. Homes are selected in November to be cleaned on November 20, 2021.

If you would only like to recommend a home at this time please select “Recommend a Home” below to submit your recommendation.

*Please note that submitting an application does not guarantee that your home will be cleaned homes must undergo an evaluation by a NeighborWorks Staff member before eligibility can be determined.

Recommend a Home

1Primary Applicant Information

2Spouse/Co-Owner Information

3Household Information

4Yard Needs

5General Information

6Authorization

Name *

First

Last

Phone Number *

Email *

Confirm Email

Date of Birth *

Age *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you own the house listed above? *

Do you have a spouse/co-owner? *

Preferred Contact Method *

Phone Call
Email
Text Message

Demographic Information

Race: Please select all that apply *

White/Caucasian
American Indian/Alaskan Native
Black or African American
Native Hawaiian/pacific Islander
Hispanic
Other
Prefer not to answer

Marital Status: Select all that apply *

Single
Married
Divorced
Separated
Widowed

Gender *

Male
Female
Prefer not to answer

Does this person have a disability? *

Yes
No
Prefer not to answer

Spouse/Co-Owner Name

First

Last

Date of Birth

Age

Demographic Information

Race: Please select all that apply

White/Caucasian
American Indian/Alaskan Native
Black or African American
Native Hawaiian/pacific Islander
Hispanic
Other
Prefer not to answer

Marital Status: Select all that apply

Single
Married
Divorced
Separated
Widowed

Gender

Male
Female
Prefer not to answer

Does this person have a disability?

Yes
No
Prefer not to answer

Family/Household Size? *

What is your household type? (Please select the most accurate) *

Female, head of house, single parent
Male, head of house, single parent
Single adult
Two of more unrelated adults
Married with children
Married without children
Other

Are you or someone in the household disabled? *

How many dependents? *

Please list the ages of all dependents?

Are there non-dependents who will be or are living in the home? *

Please list all non-dependents living in the home. Please include relationship to you and their age.

What is your level of education? *

Below high school diploma
High school diploma or equivalent
Two-year college
Bachelors Degree
Masters Degree
Above masters degree

What do you need cleaned? (Please select all that apply) *

Front and Back Yard
Front Yard Only
Back Yard Only

Do you have any fruit trees? *

Yes
No
Unknown

Do you have any pets? *

How many trees do you have? *

1-5
6-10
11-16
20 or more

How did you Hear about us? *

Friend/Family member/ Neighbor
Facebook/Instagram
Email
Newsletter or Newspaper
Mailing
Posted Flyer

Do you authorize NeighborWorks Salt Lake to give news channels your name, telephone, address for interviews, photos, and media coverage? *

Rake Your Heart Out is one of NeighborWorks Salt Lake's biggest media covered events. Please select yes if you are okay with your home being covered by media outlets.

Please add any additional Information you would like us to know.

Do you authorize NeighborWorks Salt Lake to request extra yard waste cans from Salt Lake County on your behalf? *

We partner with Salt Lake County to provide extra yard waste cans at no cost to you to dispose of the leaves and yard waste in the most environmentally friendly way possible. NeighborWorks Salt Lake will schedule the delivery and pick-up of the cans on the homeowner's behalf.

Please sign if you authorize NeighborWorks Salt Lake to (a) obtain copies of documentation pertaining to disability verification and (b) obtain verification or re-verification of any information to support statements made on this form. By signing this application, I authorize NeighborWorks® Salt Lake, its associates, volunteers, and sponsors to prepare and clean my home's exterior at the above-stated address at NO FINANCIAL OBLIGATION to my heirs or me. It is understood that NO REPAIRS to the structure can or will be made other than cleaning the home's exterior/ yard. I further acknowledge that I will receive a copy of this application for my records. I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001. *

Comment

NeighborWorks® Salt Lake
Salt Lake Office
622 West 500 North
Salt Lake City, UT 84116
Phone: 801-539-1590
NMLS #395931

NeighborWorks® Salt Lake
Murray Office
4843 S Poplar Street
Murray, UT 84107
Phone: 801-539-1590
NMLS #395931

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NeighborWorks® Salt Lake
Salt Lake Office
622 West 500 North
Salt Lake City, UT 84116
Phone: 801-539-1590
NMLS #395931

NeighborWorks® Salt Lake
Murray Office
4843 S Poplar Street
Murray, UT 84107
Phone: 801-539-1590
NMLS #395931

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