Assistance

Please fill out the form to apply for housing.

Housing Application

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First Name *

Last Name *

E-mail Address: *

Phone Number *

Applicant Social Security Number *

Applicant Date of Birth * / /

Applicant Drivers License Number *

Drivers License State *

Date of Planned Move *

Property Type (Preferred) *

Property Type (Alternate) *

Preferred County *

Number of Bedrooms Preferred *

Number of Bathrooms (Minimum) *

Number of Bathrooms (Maximum) *

Pets? *

Smoker? *

Yes
No

Applicant Current Address *

City *

State *

Zip Code *

Do you have children? *

Yes
No

If yes, how many?

1. Child's First and Last Name

Birthday / /

Social Security Number

Age

Gender

Male
Female

2. Childs First and Last Name

Birthday / /

Social Security Number

Gender

Male
Female

3. Childs First and Last Name

Birthday / /

Social Security Number

Gender

Male
Female

Race of Parent *

Race of Child 1

Race of Child 2

Race of Child 3

Are you currently homeless? *

Yes
No

Have you ever been homeless in the past? *

Yes
No

Have you ever received housing assistance from another agency? *

Yes
No

If yes, what services did you receive?

In addition to housing, what other services can we help you with? Please list them. *

What caused you to become homeless?

Where did you sleep last night? *

Where will you sleep tonight? *

Marital Status *

Spouse Name

Are you a Veteran? *

Yes
No

If yes, which branch of service?

Do you have any medical or physical disabilities? *

Yes
No

If yes, please list all medical and physical disabilities?

Are you on any medications? If so, please list them all.

Are any of your children on medication? If so please list all medications *

Have you ever had substance abuse issues? *

Yes
No

If so, please explain.

Referring Agency Name: *

Contact Name

Phone Number

Reason for Referral

Do you have a case worker? *

Yes
No

Case Worker Name

Case Worker Phone Number

Case Worker Email

Landord Name *

Monthly Rent Amount *

Rented (From Date) *

Rented (To Date) *

Landlord Phone Number *

Reason for Leaving *

Street Address *

City *

State *

Zip Code *

How long did you live at this address? *

Current Employer's Name *

Street Address *

City *

State *

Zip Code *

Employers Phone Number *

Employment Dates *

Monthly Gross Salary *

Position Held *

Unearned Income (Child Support, Unemployment, Sccial Security, etc)

Total Monthly Income *

Please list all expenses

Total Monthly Expenses *

Where are you currently living? *

Why can't you stay there? *

Do you have family locally? *

Yes
No

Are they assisting you in anyway? *

Where is the father of your children? *

Do you have a valid unexpired drivers license? *

Yes
No

Do you have your own transportation? *

Yes
No

Is there or has there been any domestic violence? *

Are there any legal issues pending? Child support custody, DFACS, divorce, probation, parole, etc *

What are you trying to accomplish? *

What would you like to tell us about yourself? *

Have you ever been convicted of a felony? *

Yes
No
Pending Charges

If yes, provide date, offense and state?

Are you currently under supervision by the following? Probation, court order, mental health court, DFACS *

Yes
No

If yes, please provide the contact name

Contact Phone Number

Agency Name *

Emergency Contact *

Street Address *

City *

State *

Zip Code *

Phone Number *

Terms and Conditions: I understand that this is a routine application to establish credit, character, employment, and rental history. I also understand that this is NOT an agreement to rent and that all applications must be approved. I declare that the statements above are true and correct, and I agree that the Agency may terminate my agreement entered into and reliance on any misstatement made above. Agreed to (check below)(*) *

* Required Free Contact Form