Housing Application Step 1 of 5 20% Your Personal InformationYour Name First Middle Last Your Email Address Enter Email Confirm Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Social SecurityDate of BirthGender Male Female Your PhoneMarital StatusSingleMarriedDivorcedSeparatedWidowedDecline to disclosePrevious/Maiden NameStudent StatusFull timePart timeNot ApplicableCo-Applicant InformationYour Name First Middle Last Your Email Address Enter Email Confirm Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Social SecurityDate of BirthGender Male Female Your PhoneMarital StatusSingleMarriedDivorcedSeparatedWidowedDecline to disclosePrevious/Maiden NameStudent StatusFull timePart timeNot Applicable General InformationPerferred Unit Size 0 Bedroom/Studio 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom Other OccupantsNameDate of BirthSocial SecurityGender Male Female RelationshipStudent Yes No NameDate of BirthSocial SecurityGender Male Female RelationshipStudent Yes No NameDate of BirthSocial SecurityGender Male Female RelationshipStudent Yes No NameDate of BirthSocial SecurityGender Male Female RelationshipStudent Yes No Rental History (Past five years starting most recent)Landlord Name First Address Street Address City State / Province / Region ZIP / Postal Code PhoneOwn or Rent Own Rent Date from MM slash DD slash YYYY Date to MM slash DD slash YYYY Monthly AmountLandlord Name First Address Street Address City State / Province / Region ZIP / Postal Code PhoneOwn or Rent Own Rent Date from MM slash DD slash YYYY Date to MM slash DD slash YYYY Monthly AmountLandlord Name First Address Street Address City State / Province / Region ZIP / Postal Code PhoneOwn or Rent Own Rent Date from MM slash DD slash YYYY Date to MM slash DD slash YYYY Monthly AmountLandlord Name First Address Street Address City State / Province / Region ZIP / Postal Code PhoneOwn or Rent Own Rent Date from MM slash DD slash YYYY Date to MM slash DD slash YYYY Monthly Amount Household and Background informationYour current housing situation is best described as:StandardSubstandardWithout or soon to be without housingConventional Public HousingLacking a fixed nighttime residenceFleeing or Attempting to flee violenceDo you currently receive subsidized housing?(Required) Yes No Do you curretnly have a voucher?(Required) Yes No If yes, AgencyAre you displaced by government action or a Presidential Declared Disaster? Yes No Do you have any pets or than service animal? Yes No If yes, typeIs head of houshold , Spouce or Co-Head currently employed? Yes No Are you a veteran? Yes No Are you or any memeber of your household subject to a State lifetime sex offender registration in any state? Yes No Have you or any memebr of your household been convicted of any crimes? Yes No Member NameCrimeStatus/DispositionMember NameCrimeStatus/DispositionHouseholds in which the Head, Spouse, or Co-Head is disabled or handicap Yes No If yes, Special requirements needed?Do any memebers of your household have conditions that requires: A sepreate room Unit for impaired vision Physical Modification to a typical unit A barrier free unit Unit for hearing impaired A mobility impaired unit Any other accommodations Household Income and DemographicsWork type Employment Self employment Military pay Unemployment Worker's Compensation Income Continued Social Security State Supplemental Income Veteran's Benefits Pension/Annuities Regular Payments from Settlement Income from trust Other retirement accounts Income Assistance TANF/Public assistance Child Support Alimony Other income Student Finacial Aid Contributions from outside household Income from Lottery winnings Income from rental property or real estate Any other income not listed Household Member Name First Income SourceIncome amountHousehold Member Name First Income SourceIncome amountHousehold Member Name First Income SourceIncome amountNarrative of how homelessness has/in impacting your life(Required)Race Ethnicity Hispanic or Latino American Indian / Alaskan Native Asian Not Hispanic or Latino Black or African American Asian Indian Decline to Disclose White Japanese Other Chinese Native Hawaiian or other Pacific Islander Korean Filipino Samoan Vietnamese Guamanian/Chamorro Other Asian Or call 207-631-1247
