AGENCY REFERRAL FOR HOUSING APPLICANT
WITH ALLEGAN HOMELESS SOLUTIONS
Please provide the full name of the applicant (head of household).
Phone Number of Applicant
-
Area Code
Phone Number
Email of Applicant
example@example.com
Current Living Situation
Car
Outdoors
Shelter
Domestic Violence Shelter
Other
Is the applicant's current living situation funded by a hotel voucher, Salvation Army funds, other? Please explain.
Is the applicant living in a dangerous situation, such as; unheated shelter in winter, public bathroom, non-working vehicle, etc. Please identify.
Does the applicant have any of the following resources: Check all the apply.
Employment
Retirement Pension
Social Security (over the age of 65)
Disability Income
Social Security Income
Child Support
Other
Does the applicant or anyone in the household who will be living in the unit, have a felony and/or are they on the Central Sex Offender Registry. If so, please explain.
Does the applicant have children under the age of 18 who will be living with them? Please list gender and ages.
Does the applicant, or anyone who will be living in the household, have special needs that require specialized housing, such as: wheelchair ramp, mobility assistance.
How likely is it that the applicant will find permanent housing in the next 2 years? Please provide details.
Does the applicant have a housing voucher? If yes, please provide more details.
Will the applicant receive case management from OnPoint? Explain.
What other agencies is the applicant working with? Please list.
Does the applicant have other resources for housing, such as; family, friends, church congregation, etc.?
If there is additional information that would be helpful to determine housing, please provide.
If you represent an agency, please provide your name and phone number below.
PLEASE NOTE: Apartment is Unfurnished. Mowing, Snow Removal, Garbage and Water/Sewer will be provided by AHS
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