NCG550233_Regional Office Physical File Scan Up To 11/9/2022

NCDEN
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Mr. David Goforth
9475 NC Highway 209
Hot Springs, NC 28743
Dear Mr. Goforth:
John E. Skvarla, III
Secretary
November 14, 2014
SUBJECT: Compliance Evaluation Inspection
Goforth Residence
Permit No: NCG550233
Madison County
On November 4, 2014, 1 conducted a compliance evaluation inspection of the
subject facility. During a review of the system file, and during a discussion with you, it
was determined that the current permittee in our system, Pearl Goforth, is deceased. As
You are the current property owner, we are requesting that you complete the enclosed
Change of Ownership form in order to have the system permitted in your name. Please .
complete the form and mail to the address indicated.
During the November 4, 2014 inspection, I collected a water sample from your
effluent pipe for analysis of fecal coliform bacteria. Those results are forthcoming and I
will provide them. -to you once they are received.
If you have any questions regarding the Change of Ownership -form, please call
me at 828-296-4500.
Sincerely,
4k Ae_t__*
Andrew Moore
Environmental Senior Technician
Enclosure
cc: MSC 1617-Central Files -Basement
�=WQ_Asheville-Files�
Water Quality Regional Operations —Asheville Regional Office
2090 U.S. Highway 70, Swannanoa, North Carolina 28778
Phone: 828-296A500 FAX: [phone]
Internet http://portal.ncdenr.org/webtwq
An Equal Opportunity 1 Affirmative Action Employer

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory, Governor
I. ' Please enter the CoC-numberfor which the change is requested.
John L. bwarla III, becretary
Certificate of Coverage
5 0 12 13 137
10
II. Please provide the following for the requested
change (revised permit).
a. Request for. change is a result of-
x Change in ownership of the residence/property
❑ Name change of the facility or owner
If other please explain:
b. Permit will be issued to (company
name, if applicable):
c. Person legally responsible for permit:
David Goforth
First MI Last
owner
Title
9475 NC Highway 209
Permit Holder Mailing Address
Hot Springs , NC 28743 .
City State Zip
[phone]
Phone E-mail Address
d. Facility name (discharge):
11 Woolyshot Branch Road
e.. Facility address:
11 Woolyshot Branch Road
Address
Hot -Springs NC 28743
City State Zip
f, Facility contact person:
First MI Last
Phone E-mail Address
III. Permit contact information (if different from the person legally responsible for the permit)
Permit contact:
First MI Last
Title
Mailing Address
City, State Zip
( )
Phone E-mail Address
Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
x Yes
❑ No (please explain)
Revised 212009

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2�
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICATION
I, David Goforth, attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my. knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information is not included, this application
package will be returned as incomplete.
Signature
Date
PLEASE SEND T_HE COMPLETE APPLICATION PACKAGE TO:
NC DENR / DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7/2008

http://www.madcotax.com/cards/8853-1.jpg ill

NCDENR P
North Carolina Department of Environment and Natural Resources .
Pat McCrory John E. Skvarla, III
Governor Secretary
December 10, 2.014
Mr. David Goforth
9475 NC Highway 209
Hot Springs, NC 28743
SUBJECT: Compliance Evaluation Inspection
Goforth Residence
Permit No: NCG550233
Madison County
Dear Mr. Goforth:
.On November 4, 2014, 1 conducted a compliance evaluation inspection of the
subject facility. A copy of the Compliance Evaluation Inspection Report is enclosed.
During the November 4, 2014 inspection, I collected a water sample from your effluent
pipe for analysis of fecal coliform bacteria. Fecal coliform bacteria were detected in the
sample at 2,200 colony forming units per 100 milliliters (CFU/100 ml), which exceeds
the General Permit limit of 400 CFU/100 ml. A'copy of the laboratory,analytical, report is
enclosed. Based on these results, the facility is found to be noncompliant with permit
NCG550233.
In order to bring the subject facility into. compliance, I recommend that you have
your septic tank pumped as soon as possible..As you and I discussed on the -phone,
your system may. need an upgrade to include 'chlorination and dechlorination to bring. it
into compliance. There, may be funding opportunities available to make the.upgrades to
your system. I will keep you. informed of those opportunities as they become available.
Please refer to the enclosed inspection reportfor additional observations and
comments. If you have any questions, please call me at 828-296-4500.
Sincerely,
Andrew Moore
Environmental Senior Technician
Enclosure , _
cc: MSC 1617-Central Files -Basement
WQ Asheville -Files
Water Quality Regional Operations — Asheville Regional Office
2090 U.S. Highway 70, Swannanoa, North Carolina 28778
Phone: [phone] FAX: [phone]
Internet: hffp:/lpodal.ncdenr.org/web/wq
An Equal Opportunity 1 Affirmative Action Employer

United States Environmental Protection Agency
Form Approved. .
EPA Washington, D.C. 20460
OMB No. 2040-0057. -
Mater Compliance Inspection Report...
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type
Inspector Fac Type
1 LJ 2 LJ 3 I NCG550233 I11 12 14/11/05 17 . • 18.1 r+.l
19 1 S I : 201 I. "
211 1 1 1I I I I I I I I I L I I I I I I I •1 1 1 1 1 1 1 1 1 1 I I .I
I 11, I I l l 1. f 6
Inspection
Work Days Facility Self -Monitoring Evaluation Rating .8,1 QA
Reserved-
67
-72 N 73 L.74 751 I 1 . �. ..,i80
70 71Li LJ
Section B. Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging.to POTW, also include
Entry Time/Date
Permit. Effective Date
POTW name and NPDES permit Number) .
• i
10:15AM ., 14/11/05 .
13/08/01
11 WoDlyshot Branch -Road
11 Woolyshot Branch'Rd
Exit Time/Date
Permit Expiration Date
Hot Springs NC 28743
10:30AM 14/11/05
18/07/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax.Number(s)
Other Facility Data
Name, Address of Responsible Officialfl•itle/Phone and Fax Number
Contacted
i
Arthell Goforth,Rt 1 Box 26 Hot Springs NC 28743//704-622-7150/
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Operations & Maintenance Effluent/Receiving Waters
Section D: Summary of Finding/Comments (Attach additional_ sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers -
Date
Andrew W Moore ARO WQ//828-296-4684/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers
Date
EPA•Form 3560-3 (Rev 9-94) Previous editions are obsolete.
i
Page# 1

NPDES yr/mo/day Inspection Type (Cont.) 1
31 NCG550233 I11 12 14/11/05 17 18 I C I
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
The current permittee, Pearl Goforth, is deceased. The current owner, David Goforth, should complete
the previously provided Change of Ownership form.
The Asheville Regional Office does not have any plans or construction details for the system. The
original installer, Ken Pangle, was contacted and indicated the system consists of a 900 or 1,000
gallon septic tank, a 24' lined filter system consisting of interlayered sand and gravel, and an effluent
discharge pipe. The effluent discharge pipe was observed to be discharging at the time of the
inspection. No other infrastructure associated with the discharge system was observed at the time of
the inspection.
A water sample was collected from the effluent discharge pipe.at the time of the inspection and
analyzed for fecal coliform bacteria. The results were.2,200 CFU/100 ml, which exceeds the daily
maximum. of 400 CFU/100 ml resulting in noncompliance with the General Permit conditions.
It is recommended that the septic tank be pumped immediately.
Page# 2

Permit: NCG550233 Owner - Facility: 11 Woolyshot Branch Road
Inspection Date: 11/05/2014 Inspection Type: Compliance Evaluation
Permit
Yes No NA NE
(If the present permit expires in-6 months or less). Has the permittee.submitted a new
11,
❑
M
❑
application? .
Is the facility as described in the permit?
❑
❑
MEI
# Are'there any special conditions for the permit?
❑
❑
M
❑
Is access to Jhe plant site restricted to the general public? .
❑
❑
0
❑
Is the inspector granted access to all areas for inspection?.
0
❑
❑
❑
Comment: The current permittee, Pearl Goforth, has been deceased for many
years. The new owner,
.
David Goforth, should comMete a Change of Ownership form.
Operations $ Maintenance Yes No NA NE
Is the plant generally clean with acceptable. housekeeping? M ❑ ❑ ❑
Does the facility analyze process control parameters, for ex: MLSS,.MCRT, Settleable ❑ ❑ .❑
Solids, pH, DO, Sludge Judge,.and other that are applicable?.
Comment:
Septic Tank
Yes No NA' NE
(If pumps are used) Is an audible and visual alarm operational?
❑ ❑
❑
Is septic tank pumped on a schedule?
❑
❑
❑
Are pumps or syphons operating properly?
❑ ❑
❑
Are high and low water alarms operating properly?
❑ ❑
M
❑
Comment: The septic tank has never been pumped to the current owner's knowledge.
The septic tank
should be pumped every five years or when the solids level is found to be more than 1/3 of
-the liquid depth.
u
Page# 3

County: POLK
Qk WgrFR
Sample ID:
AC14294
River Basin
PO Number #
ARO
Report To AROSP
Date Received:
11/04/2014
;,
y -
Time Received:
15:06
Collector: A MOORE
Labworks LoginlD
KJIMISON2
Region: ARO
Final Report Date:
11/28/14
Sample Matrix: WASTEWATER
FIhBllRe: 6-16*w
Report Print Date:
12/08/2014
Loc. Type: EFFLUENT
Emergency Yes/No
ViSitlD
COC Yes/No
Loc. Desch: 11 WOOLYSHOT BRANCH RD
Location ID: 1P057NCG550233
Collect Date: 11/04/2014
Collect Time: 10:30
Sample Depth
If this report is labeled preliminary report, the results have not, been validated. Do not use for Regulatory purposes.
Result/
Method
Analysis
vr-ry rr nIIca y a ivaiuc r�t�. Duna
Qualifier Reference Date .
Others
Sample temperature at receipt by lab 3.7 °C 11/4/14 RBYRD
C011form, MF Fecal in liquid 1 2200 B3 CFU/100ml APHA9222D-20th 11/4/14 CGREEN
/
Laboratory Section>> 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed description of the qualifier codes refer to hto://portalncdenromlwebnvaAab sash o(techeeeetaoaW xly Ifler Codes chroll-a Lncdenr.oml�„gb/wo/lab/saB0i.,'—hasxsr
Page 1 of 1

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Communitv Housing Coalition of Madison Coun
P.O. Box 1166, Marshall, NC 28753
www. chcmadisoncountEnc. or
Office Phone: [phone]
Thank you for contacting the Community Housing Coalition (CHC) of Madison County. We are a 501(c)(3)
non-profit organization, serving Madison County by promoting decent, safe, and affordable housing. through
advocacy, education, coordination of services and resource development to meet the housing needs of our
communities.
L Completion of this application will allow us to maximize the resources that may be available for your
assistance.
Enclosed are the following:
• CHC Assistance Policy —this is yours to keep.
• Application for Assistance
Once completed, please 'send us the Application for Assistance form, so that we may, begin processing your
application. You can mail completed applications to:
Community Housing Coalition of Madison County, Inc
P.O. Box 1166
Marshall, NC 28753
We hope to be able to serve you and your family, but due to a large number of applications, it is impossible to
meet the needs of every person applying. We will contact you regarding the status of your application shortly,
but please be patient as we will be receiving and assessing many applications in the following months. If there
are any questions concerning this application, please call Community Housing Coalition at 828-649-1200 or
visit our website at www. chcmadisoncountync. org .
Sincerely,
CHC of Madison County

Community Housing Coalition of Madison Coun
P.O. Box 1166, Marshall, NC 28753
www. chcmadisoncountync. org
Office Phone: [phone]
Assistance Policy
This Assistance Policy describes who is eligible to apply for assistance from the Community Housing Coalition
of Madison County, how applications for assistance will be rated and ranked, what the form of assistance is, and
how the repair/modification process will be managed.
CHC Goals:
1. To alleviate housing conditions which pose an imminent threat to the life or
safety of very low-income homeowners as well as those with special needs; and
2. To provide accessibility modifications and other repairs necessary to prevent displacement of
very low-income homeowners with special needs, such as frail elderly and persons with
disabilities.
Eligibility: To be eligible for assistance from Community Housing Coalition, applicants:
1. Must reside within Madison County
2. Must either own and occupy home in need of repairing or, applicant must show written
approval from landlord to have work performed on home.
3. In most cases, must have a household income which does not exceed 50% of Madison
County's median income for the household size (as indicated by the table on the next page).
4. May have household income up to 80% of Madison County's median income if also
qualifying under,CHC's priority special needs populations.
Attributes that define CHC's priority special -needs populations:
*Elderly: An individual age 62 or older.
*Disabled: A person who has a physical, mental, or developmental disability that greatly limits one or more
major life activities, has a record of such impairment, or is regarded as having such impairment.
*Single -Parent Household: a household in which one and only one adult resides with one or more dependent
children.
* Very Low Income: Total Household income is below 50% of Area Median Income.
Other Definitions:
*Head of Household. The person or persons who own(s) or rent(s) the home.
*Household Member: Any individual who is an occupant (defined below) of the unit to be rehabilitated shall
be considered a "household member." The number of household members will be used to determine household
size, and all household members are subject to income verification.
*Occupant. Any immediate family member (mother, father, spouse, son or daughter of the head of the
household, regardless of the time of occupancy); or non -immediate family member who has resided in the
dwelling at least 3 months prior to the submission of the family's application.
*Extreme Emergency: A situation in which serious harm would befall the occupants of the home, such as no

heat during cold weather, roof or wall damage caused by fire, wind or falling trees, water leaks that may
inundate electrical circuits or outlets.
Annual Income Oualification Limits for Madison Residents
ouse old
30° o t)f e ian , c
o edia
t 11a e o e s- eia e
1
$11,800
$19,600
$31,200
2
$13,450
$22,400
$35,650
3
$15,250
$25,200
$40,100
4
$16,800
$28,000
$44,550
5
$18,150
$30,250
$48,150
6
$19,500
$32,500
$51,650
7
$20,850
$34,750
$55,250
8
$22,200
$37,000
$58,800
CHC Priority Ranking System
CHC gives priority to applicants who meet some or all of the following special needs:
Special Needs
oints
Less than 30%.of County Median Income
10
Less than 50% of County Median Income
5
Elderly Head of Household (62 or older)
4
Disabled Head of Household
4
Disabled or Elderly Household Member
3
Single -parent Household
2
Screening of applicants: Recipients will be prioritized by the above criteria without regard to race, creed,
sex, color, national origin, religion, or sexual orientation. Household income will be verified ,for program
purposes only (information will be kept confidential).. Ownership of property will be verified along with other
rating factors. A CHC employee or designee will visit the home of applicants to determine the need and
feasibility of repairs/modifications.
How does CHC help?. CHC will provide materials and the services of volunteers or professionals, as
available, to repair the urgent need of the homeowners whose homes are selected for repair/modification. This
assistance is not a loan. No repayment on the part of the homeowners will be expected., Provision of repairs is
subject to availability of funding and volunteers. When applicable, clients will be referred to outside resources
such as Independent Living, Vocational Rehabilitation, USDA, Community Action Opportunities, Veterans
Assitance, etc.

How much will be spent on each project? The amount of money spent on each project depends on the
scope of the work necessary to address the identified imminent threats to life and/or safety, and that will be
determined by CHC.
What kinds of work will be done? Only repairs that address imminent threats to the life or safety of
occupants of the dwelling or accessibility modifications are performed by CHC. In typical cases, work may
include repairing rotten flooring, ceilings or walls and the leaks that caused the rot, repairing and/or replacing
damaged roofs; updating and/or repairing electrical wiring; building handicap ramps and/or safety railings;
plumbing, etc.
Who will do the work on the homes? CHC matches projects to volunteer teams or individuals
interested in helping neighbors in need. In those cases where professional labor is required, CHC selects
contractors who have demonstrated a high degree of skill and ability. All contractors are given equal
opportunity to bid. Each contractor will be reviewed by the CHC board based on references and recent jobs.
Each job will be rewarded to the lowest responsive and responsible bidder. "Responsive and responsible"
means the contractor (1) is deemed able to complete the work in a timely fashion, and (2) that the bid is within
15% (in either direction) of CHC's cost estimate. Approved contractors will be asked to submit bids on each
project. Applications for bidding are available at the CHC office or can be mailed upon phone request. Ads
will be placed as needed in the News Record and Sentinel to inform the public about opportunities to bid.
How will clients be referred? CHC will place quarterly ads in the Madison County News Record and
Sentinel to inform the general public that applications and services are available. Clients are also referred by
our partnering agencies such as Community Action Opportunities, Independent Living, Madison County public
agencies, USDA, etc. Any client referred by a partnering agency will be called and sent an application.
Is there a procedure for dealing with complaints, disputes or appeals? Although the
application process and repair/modification guidelines are meant to be as fair as possible, the CHC realizes that
there is still a chance that some applicants or participants may feel that they are not treated fairly. The
grievance procedure will be discussed with each homeowner before work begins.
If an applicant has a complaint during the application process, the following steps should be taken:
1. If an applicant feels that his/her application was not fairly reviewed or rated and would like to appeal
the decision made about it, he/she should contact the director within 30 days of initial notification. If the
applicant remains dissatisfied with the decision, the detailed complaint should be put into writing.
2. A written appeal must be made to the CHC board within 10 business days of the conversation voicing
dissatisfaction. Email complaint to CHC Board President, Lee Hoffman at
hoffman317gmsn.com
3. CHC will respond in writing to any complaints or appeals within 30 days of receiving written
comments. The CHC board meets monthly.
Will personal information provided remain confidential? Yes. All information in applicant files
will remain confidential. Access to the information will be provided only to CHC staff who are directly
involved in the program and upon request to CHC's auditors.
What about conflicts of interest? No officer or employee of the Community Housing Coalition shall
have any interest, direct of indirect, in any contract or subcontract for work to be performed with program
funding, either for themselves or those with whom they have family or business ties. Relatives of CHC board
members or staff may be approved for rehabilitation assistance only upon public disclosure of such a connection
to the CHC board.
What about favoritism? All CHC activities, including rating and ranking applications, inviting bids,
selecting contractors and resolving complaints, will be conducted in a fair open and non-discriminatory manner,

entirely without regard to race, creed, sex, color, national origin, religion, sexual orientation, or political
affiliation.
How soon will work be done? Once an application has been received by C-HC, every attempt will be
made to notify the client that the application is being processed within two weeks. In most cases work that is to
be performed by volunteers will be carried out during June and July of each year.
What if I have more questions? Any question regarding any part of this application or program should
be addressed to: -.
Chris Watson (Client Intake & Project Manager)
Chris W 2chcmadisoncountync.org
828.649.1200
June Trevor (Client Intake & Volunteer Coordinator)
June(cr�chcmadisoncoun nc.or-9
928.649.1200
Christopher Brown (Director)
Chris(a?chcmadi soncountync.org
828.649.1200
How do I get an Application? Just contact:
Community Housing Coalition of Madison County, Inc.
P.O. Box 1166
Marshall, NC 28753
828-649-1200
Applications can also be downloaded from CHC's website: www.chcmadisoncountync.or
Completing an application form: Proof of ownership or permission from landlord and income will be
required. Those who have applied for housing repairs.in the past will not automatically be reconsidered or
denied. A new application will need to be submitted in order for new needs to be considered. NOTE: Income
of all occupants of the house will be considered.
ee
Lee Hoffmann, Board Chair

rAT"tal
Communitv Housing Coalition of Madison Coun
P.O. Box 1166, Marshall, NC 28753
www. chcmadisoncounVnc. org
Office Phone: [phone]
Application for Assistance
Date:
Name of Applicant
Street Address
City ZIP Code
Mailing Address (if different)
Home Phone:
Contact Name:
Home Phone
Work Phone:
Relationship:
Work Phone:
Have you received assistance from CHC in the past? Yes ❑ No ❑ If yes, please describe when and
what work was performed.
Briefly describe the problems that need repairing:
Type of dwelling: Frame House ❑ Mobile Home ❑ Brick house ❑ Other ❑
Do you own/are you buying your dwelling? 'Own ❑ Own with Mortgage ❑
If renting, do you: Own Home & Rent Lot ❑ or Rent Lot and Home ❑
If renting, please provide the name of the land and/or home owner:
What actions have been taken to fix the problems?
Briefly describe any disabilities of any members of this household:
Does any member of the household receive Social Security Disability? Yes ❑ No ❑
Are you or any member of your family a Veteran? Yes 0 No 0

Household Membership
Name (first, MI, last)
Sex
Age
Social Security Number
Relationship to Applicant
1.
2.
3.
4.
5.
If more than 5 people in this house, add their names and information on an attached sheet.
Gross Income Work Table Dollars earned by each household member per month
Sources of Income No. I No. 2 No. 3 No. 4 No. 5
Wages
Retirement/Pension
Social Security
Supplemental Security Income
Public Assistance
Child Support
Interest
Other (Including Property, etc)
Monthly Subtotal for Each
If more than 5 people live in this house, add their names and information to an attached sheet.
Monthly Household Total Income (add totals for each wage earning resident):
Amount of monthly household income that is spent on recurring medical treatment and/or maintenance
medications:
Explain:
Please provide proof of income (bank statement, Social Security statement...) with application
If renting, do you have written permission from landlord for work to be done? Yes ❑ No ❑
This will be required before any work begins. Please attach to application before turning in.
If you own land, how many acres of property do you own?
What year was your house built?
How did you hear about CHC?
Before submitting your application for assistance, please make sure you have:
- signed Release and Indemnification
- signed the last page of the Application for Assistance
- included proof of income
- provided proof of title for any mobile home on a rented lot
- written permission from landlord allowing for repairs if applicable

Applicant Certifications:, I hereby certify that...
1- I own and occupy the home described above or am showing written permission from my landlord to
modify my home.
2- The above information is complete and true to the best of my knowledge.
3- 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.
4- I give permission for CHC personnel to access information to verify the'contents of this application and
to facilitate the repair of my home.
5- 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.
Applicant Signature:
Mail this completed application to :
Community Housing Coalition of Madison County, Inc.
P.O. Box 1166
Marshall, NC 28753
828-649-1200
Date:
We hope to be able to serve you and your family, but due to a large number of applications, it is impossible to meet the
needs of every person applying. We will contact you regarding the status of your application shortly, but please be patient
as we will be receiving and assessing many applications in the following months.. If there are any questions concerning
this application, please call Community Housing Coalition at 828-649-1200 or visit our website at
www.chcmadisoncountync.org .
Office Use Only
Date Received:
Date Assessed: / / Assessor:
Notes:

Community Housing Coalition of Madison County
Indemnification and Release Form
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 the 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 the CHC
from any liability whatsoever for supplying such information.
• I, HAVE CAREFULLY READ AND UNDERSTAND
COMPLETELY THE ABOVE PROVISIONS AND VOLUNTARILY SIGN THIS INDEMNITY
AND RELEASE AGREEMENT.
• Circle: YES or NO. 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.
Print Name:
Signature:
Date:
P.O. Box 1166 Marshall, NC 28753 828-649-1200 www.chcmadisoncouiitync-.org
(Updated Jun 19, 2014)