Minor Home Repair Application

Please complete the enclosed application. Copies of ALL required documents must be attached to your application. MHR assistance will be provided on a first applied, first served basis.

MHR Assistance Available:

1. Weatherization, energy efficient lighting

2. Wheelchair ramps, handrails, other safety and accessibility repairs

3. Minor home repairs including: broken windows, door locks, interior hand rails/grab bars

All documents are REQUIRED for consideration for MHR assistance. Please attach copies of the following documents

Household Income must be at or below 150% of Federal Poverty Level

Family Size	1	2	3	4	5	6
Income Limit	$19,140	$25,860	$32,582	$39,300	$46,020	$52,740

Before filling out the application, please read and sign your initials for each statement below.

MAACLink is a computer system that is used locally as a Homeless Management Information System (HMIS). Use of an HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. MAACLink is not electronically connected to HUD and is only used by authorized agencies. All MAACLink users have received confidentiality training and have signed strict agreements to protect clients' personal information and limit its use appropriately.

A Privacy Notice is available at participating agencies. It provides details on how member agencies and their employees handle client information and data sharing.

I give permission to Metro Lutheran Ministry to collect and enter my personal and household information into the MAACLink computer system.

I understand that the MAACLink system is shared with and used by authorized agencies in my community for the purposes of:

1. Assessing the needs of low-income, homeless or other people with special needs in order to give better assistance and to improve their current or future situations.
2. Improving the quality of care and service for people in need. 
3. Tracking the effectiveness of community efforts to meet the needs of people who have received assistance.
4. Reporting data on an aggregate level that does not identify specific people or their personal information.

I understand that:

• All agencies that use MAACLink will treat my information in a professional and confidential manner.
• Signing this release form does not guarantee that I will receive assistance.
• My information may be shared with a third party (utility provider, landlord, etc.) in order to process the service I have requested.
• I have the right to a printed copy of my MAACLink file.

Each MAACLink agency will ask you to sign this form at least annually. If after you give consent you decide you no longer would like your information entered into MAACLink, please complete the Client Revocation Form. If you do not revoke this authorization, it will automatically expire one year from the date you sign and date this form.