Camillus House HPRA Questionnaire

1
Applicant's Name* This field is required.
First Name
Middle Name
Last Name
Suffix
2
Preferred Method of Contact* This field is required.Only 1 form of contact is required
Please enter your email
Please enter your phone
3
***Press Next if you are not Camillus House Staff***Call Center Agent Name
4
Which county are you a resident of?* This field is required.
Miami-Dade
Broward
Monroe
5
Do you have a pending application, or are you receiving assistance from another organization, for the same assistance being requested from this program?* This field is required.
YESNO
6
Do you have any support system or family who can provide you with immediate housing?* This field is required.
YESNO
7
Do you have any other resources, housing options, family or support networks that can help instead of requesting this assistance?* This field is required.
YESNO
8
Are you currently fleeing domestic violence, labor or sex trafficking?* This field is required.
YESNO
9
Are you an unaccompanied or parenting youth who has not turned 25 years old? * This field is required.
YESNO
10
Do you have documentation to demonstrate imminent risk of homelessness, as evidenced by one of the following: * This field is required.Scroll through the 11 choices and check all that apply.
Court document showing you are in the process of being evicted
Documentation verifying you are staying in a hotel/motel not paid for by a government agency or non-profit
Referral from Fire Department/Red Cross and Fire Incident Report
Government document proving the building you were living in was condemned
Letter from institution or transitional housing you are leaving verifying homeless status prior to entering
Document verifying home you were living in was foreclosed on
Letter verifying you’re aging out of foster care or on family unification program
3-Day Notice from Landlord showing you are behind on rent
Referral from Project UP-START along with Doubling Up Letter and Proof of Address from host or Motel Receipts
Section 8 Authorization for Change of Dwelling
None of the above
11
How many people are in your household (including yourself and minor children)?* This field is required.
1
2
3
4
5
6
7
8
9
10
11+
12
What is the total household income for all persons residing with you (include your income)?* This field is required.
Please Select
Please Select
$0 - $20,500
$20,501 - $23,400
$23,401 - $26,351
$26,351 - $29,250
$29,251 - $32,470
$32,741 - $37,190
$37,191 - $41,910
$41,911 - $46,630
$46,631 - $51,350
$51,351 - $56,070
$56,071+
13
Current Home AddressIf no street address is available, please fill out your current city, state, and zip code.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
$TotalPeople
15
$TotalIncome
16
$UniqueID
17
_Qualified
YESNO
18
_DocIDs
19
_IncomeID
20
_CountyResidency
21
_TotalPeople
22

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