Emergency/Transitional Housing Application

Emergency/Transitional Housing Application
Date

Month Day Year
Date Hour Minutes AM/PM Option
Head of Household Name *

First Name Last Name
Sex *

Female Male
Social Security Number will be required in person at the interview.
Date of Birth *
Martial Status *
Phone Number

Area Code Phone Number
Email
example@example.com
Previous Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Driver License #
Driver License State
Spouse Name

First Name Last Name
Spouse Date of Birth
Spouse's Social Security Number will be required in person at the interview.
Spouse Driver License #

Others in Household Requiring Shelter

	Full Name	Relationship	Age	Sex	Date of Birth
1
2
3
4
5

Resources ($ Amount)

	Resources ($ Amount)
Work
SS
SSI
AFDC
Child Support
Family Support
Workman's Comp
Money on Hand
Food Stamps
Other

Services You Can Provide to Help

	Services You Can Provide to Help
Prepare Meals
Clean Kitchen
Wash Dishes
Clean Day Room
Vacuum/Mop/Sweep
Clean Bathroom
Clean Laundry Area
Clean Yard
Cut Grass
Work for Non-profit Organization
Other (explain)

More Information

Please share with us the information concerning your needs and plans.
Why don't you have permanent housing? *
Are you requesting emergency shelter for more than one night? If so, why? *
What steps are you taking to secure permanent housing within the allotted time? *
Please list the name, address and telephone number of 2 personal references and one professional reference. (Not related to applicant.) *
Do you work? If so, where? *
What is your current living situation? (Street/Outdoors, Car, With Relatives, etc.) *
What is your current living situation? (Street/Outdoors, Car, With Relatives, etc.) *
Do you have a felony record? If yes, please explain. *
Has anyone in your household been arrested in the last 2 years? If yes, please explain. *
Any chemical dependency and/or alcohol use? *
Have you applied for Section 8 or Public Housing? Have you lost any Section 8 or Public Housing privileges? *
Notes / Comments
Terms and Conditions: I certify that to the best of my knowledge the above information is true, and I give my permission to verify said information. Falsification of any information may be grounds for immediate denial. Upon signature I authorize a release of information on myself and listed members of my household into secured Service Point database. If needed I authorize a release to area churches.
Terms and Conditions *
Please verify. *
Signature *

Clear
A Photo ID, Social Security Numbers and proof of income will be required at the interview. You will also be required to sign in person.
Should be Empty:

Emergency/Transitional Housing Application

More Information