Today’s Date: ___________ Family Name:_________________________________________________Home Address: ______________________________________________________________________Contact Person:Home Phone:____________ Work Phone:_____________ Cell Phone:________________E-mail:_________________________________________________________________

Who holds the title deeds to the property and house? __________________________________________ Is there a video enclosed with your application? Y/N Are there pictures enclosed with your application? Y/N

Household Income (Month/ Year): Under 15,000 15,000 – 50,000 50,000 – 75,000 Over 75,000

Age Name DOB Relationship Occupation /Education Level1

2

3

4

5

List ALL members currently living in the household (Including Yourself):

Thank you for your interest in applying for ARAWAK CEMENT Home Sweet Home: TV SHOW. We are looking for families that are in need and deserving. In order to be considered you must complete this application and submit recent still photos and/or video of the nominated house. Please know that anything you send to us will not be returned. If you are nominating a family you know, please include their information throughout the application. There will be a separate spot on the application for your contact information. If you are nominating a family that you don’t know or perhaps you read a news article about them), please just include the information that you do have and if we are interested, we will try to locate them.

PART 1: FAMILY’S INFORMATION

If residents are employed, indicate their employer(s) and job title(s)1.________________________________________________________________________2.________________________________________________________________________ Does the owner of the house, or anyone in the household receive government assistance?Amount per mouth: Recipient:1. ____________ ____________________2. ____________ ____________________ Please describe any volunteer work or community service your family has been involved in: _____________________________________________________________________________________________________________________________________________________________________________________ Do you have any debt other than your home mortgage? Y / NIf yes, please describe: _____________________________________________________________________________________________________________________________________________________________________

IF YOU ARE NOMINATING A FAMILY, PLEASE INCLUDE YOUR INFORMATION:Name: _______________________________________________________________Address: _____________________________________________________________Home Phone: _____________ Work Phone: _____________ Cell Phone:___________Relationship to the Family:________________________________________________

ARAWAK CEMENT FAMILY APPLICATIONTV SHOW

PART 2: YOUR FAMILY’S STORY (Mandatory)

Please summarize the/your family’s CURRENT situation and how it affects you/them. What makes you/them deserving? `What makes you/ their situation unique? (Please keep your answer brief)_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Number of levels: ___________________________Total # of bedrooms: _________Total # of bathrooms: ____________Does the house have a basement or cellar? Y / NSquare footage of house: ___________________________________Lot Size: _________________________________Do you own your home? Y / NIs the Deed to your home in your name alone? Y / NIf not, whose name is on the house deed? ________________________________________________How much do you owe on your home as of the date of this application? ______________________________________________________________________________________________

Do you have any liens on your home? Y / NIf yes, please describe who holds the lien and how much is owed: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If selected to participate, you may be filmed, videotaped and photographed, and your name, image and likeness may be used in or to publicize a television show. By signing below, you waive any rights of privacy or publicity in connection with this production and certify that all information stated by you on this Application Form is true.

____________________________(Signature)

PART 3: YOUR HOUSE AND NEIGHBORHOOD

Why does this home need a makeover? What are the top FIVE repairs that need immediate attention?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________