Emergency/Transitional Housing Application

Date

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)

Work

SS

SSI

AFDC

Child Support

Family Support

Workman's Comp

Money on Hand

Food Stamps

Other

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)

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.) *

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.

Emergency/Transitional Housing Application

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