Home SEEKER Application

Dear applicant,

Thank you for your interest in ElderHelp’s HomeShare Program. The purpose of the program is to match people looking for a housemate with individuals seeking affordable housing. It is an opportunity to lower your housing costs while remaining independent at home.

Before you decide to start the enrollment process, please take a look at the “Eligibility Criteria for HomeShare Seeker Applicants.” If you decide to enroll in the program, please read the “Home Seeker Information” thoroughly, and complete this HomeShare Seeker Application.

Upon receipt, we will review your application for eligibility and suitability for the HomeShare Program. After we have reviewed your application, we will send a letter updating you on the status of your application. For that reason, it is vital that you have a valid mailing address and telephone number so that we are able to contact you.

Please note that if you are accepted into the program, finding a suitable match may take time, and is not guaranteed. We strongly encourage you to pursue other housing options in addition to the HomeShare Program.

For any inquiries about the program and the process, please read the entire “Home Seeker Information” packet before you contact us. The information you are looking for may be included in the packet. If you still have questions once you’ve read the entire packet, please call 619-284-9281.

If you are in immediate need of shelter, please call 2-1-1 San Diego or the County of San Diego (800-510-2020) for information about shelters, transitional housing, low rent and subsidized senior apartments.

Sincerely,

The HomeShare Team

Step 1: Check Your Eligibility
• MUST be physically, mentally, emotionally, and financially self-sufficient

• MUST be able to afford at least $600 per month in rent

• MUST have valid telephone number and local mailing address, Photo identification, and Proof of income (2 recent bank statements, paycheck stub, or letter from Social Security Administration)

• MUST pass a criminal background check (no convictions of any felony, misdemeanor crimes involving bodily injury, assault, elder abuse, sexual offenses, possession or distribution of an illegal substance, or theft of personal property)

• MUST sign statement confirming sobriety for at least one year

• MUST complete a Healthcare questionnaire signed by healthcare providers including physician, psychiatrist, social worker, or therapist

• MUST provide references (supervisor, landlord, and personal references not related to you)

• MUST provide a copy of driving record from Department of Motor Vehicles

• NO evictions within the last two years (applications with three or more evictions are not eligible)

Please read our HomeShare Program Guide for full details. At this time, our Home Seeker applicants greatly out number the inventory of available rooms for rent. There is no guarantee that we can place Home Seeker applicants into a HomeShare match.

And, check out our ElderHelp 2020 Affordable Housing Guide to discover other transitional housing, senior residences, resources for Veterans, and affordable housing resources in the San Diego Area.

If you have any questions, please reach out to one of our HomeShare Coordinators. We look forward to assisting you!

Step 2: Personal Information
Full Name*

First NameLast Name
Date

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Date of Birth. Must be 18 years old or older.*

MonthDayYear
Age:*
E-mail
Where did you hear about the HomeShare Program?*
Have you applied to the HomeShare program before?*
What is your preferred language?*
Do you speak any other languages? If so, please list here:
What is your gender?*
What gender roommate are you seeking to live with?*
Please check the box below if you are seeking housing for yourself and an additional person(s):

Yes, I am seeking housing for myself and an additional person(s)
Please list name(s), gender, age(s) of additional person(s)
Are you willing to share a home with someone who has children living with them?*

YesNo
Please check the box below if you are currently vaccinated:

Yes, I am vaccinated
Are you willing to live with someone who is unvaccinated?*
Please select your race/national origin:*
Please select your ethnicity:*
Are you a Veteran or Veteran Spouse?*
Are you currently experiencing or at risk of homelessness?*
Please describe the level of homelessness you are experiencing:*
Are you on the Section 8 waiting list?*
Are you receiving a Section 8 voucher?*
Have you ever been convicted of a felony?*

YesNo
If yes, when and describe.*
Persons convicted of any felony, misdemeanor crimes involving bodily injury, assault, elder abuse, sexual offenses, possession or distribution of an illegal substance, or theft of personal property are not eligible for the HomeShare Program.
Do you have a history of evictions?*

YesNo
If yes, when and describe.*
Persons with evictions within the last two years and persons with three or more evictions are not eligible for the HomeShare Program.
Please select all of the following that are applicable to you (can select multiple):*
Please share any relevant information regarding the above conditions. We would like to have a better picture of your mental and physical health so that we can determine your eligibility for our program.*
Have you had any injuries, falls, or hospitalizations within the last year?*
Please provide a brief description of the circumstances (including how often you have been to the hospital in the past year):*
Do you currently need assistance with any ADLs? (bathing, dressing, taking medications, eating, toileting, transferring, etc.)*
Is anyone assisting you with any of the activities listed above?*
Please explain:
Are you currently being treated by a physician, psychiatrist, or therapist?*
Please explain:
Emergency Contact

Step 3: Housing History and Preferences
Which type of HomeShare match are you interested in? (please select one)*
Please select all of the types of services that you would consider providing (can select multiple):*
What's the maximum number of hours per week you are willing to provide services?*
# hours per week
What regions in our ElderHelp Service Area are you be willing to live in? Select all that apply*
Please check the box below if you prefer to live somewhere without stairs:

Prefer No Stairs
What type of home are you looking to live in? Please select all that apply.*
What are your bathroom preferences?*
Do you smoke?*
Please check the box below if you are willing to live with a smoker:

Willing to Live With a Smoker
Do you have a history of drug or alcohol abuse?*

YesNo
How long have you been clean and sober?*
Can anyone attest to your sobriety?*

YesNo
Do you have pets?*

YesNo
Please provide details about pet (type, size, number of pets, name, etc.):*
Please check the box below if you are willing to live with pets:

Willing to Live With Pets
State any other relevant information you would like our HomeShare Team to know and consider.

Step 4: Financial Information
What are your sources of income? Select all that apply.*
What is your annual income? (How much money do you make EACH YEAR?)*
How much are you able to pay for rent each month?*
What is the maximum amount that you would be willing to pay for rent?*
Receipt of ElderHelp HomeShare Program Information
By signing below, you consent to the following statement:

I have received the Home Seeker Information Packet outlining the current HomeShare Program policies. I have either read it, or had it read to me carefully. I agree that I will maintain and abide by all HomeShare policies while participating in the HomeShare Program. I understand that this document has been prepared for the information/guidance of all HomeShare participants. It is intended to cover the policies and conduct most often applied to HomeShare activities. I accept that, with time, the information will change as these policies are under constant review. I understand that I will be notified in writing of any such changes.
Electronic Signature*

Clear
Date

MonthDayYear
Date
HS Coordinator Email Notification

rstrickland@elderhelpofsandiego.orgvolunteer6@elderhelpofsandiego.orgCMorrris@elderhelpofsandiego.orgELandsman@elderhelpofsandiego.orgesappington@elderhelpofsandiego.orgbhodgkinson@elderhelpofsandiego.org
Company

Home Seeker
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