Housing Assistance Application Form

Housing Assistance Application

PO Box 1776, Petersburg, AK 99833
Today's Date*

MonthDayYear
Name*

First NameMiddle NameLast Name
Legal Name if different

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Address

Street Address

Mailing Address

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
Has your household been adversely impacted by the Covid-19 Pandemic?*

YesNo
Have you received COVID-related rent relief?*

YesNo
Ethnicity*
Race*
Gender*
Additional Household Members
Are you or anyone in your household living with a disability?*

YesNoDecline to answer
Are you or anyone in your household a Veteran?*

YesNoDecline to answer
I am requesting assistance for the following:*

Housing AssistanceUtility AssistanceNew Housing AssistanceOther
Household Type*
Choose the option that best represents you.
Current Housing*
Choose the option that best represents you.
Household Income Information

Include income for all household members
Income total income from all sources in the last 30 days*
Enter Zero if No Income
Statement of need/Income explanation
Explain any impacts to income sources.
Vendor Information (Landlord, Utility Company)

Payments will be sent directly to vendor
Vendor *
Who do we need to pay?
Vendor Phone Number
Vendor Address to Mail Check*

Mailing Address

CityState

Zip Code
Amount Requested*
Minimum amount needed*
Amount needed to prevent homelessness/utilities shut off
Signature Page
I authorize the release of information from my rental/utility vendor Rental/Utility Vendor* to Humanity In Progress (HIP) and further authorize HIP to communicate wit my vendors on my behalf as it relates to the assistance program.
I understand that my household can submit only "one" application for Assistance per program year and that the home I am applying for is the home I live in.

I understand that it is against the law to make false statements, and that I am subject to prosecution if I do.

I understand that HIP will confidentially use this information to provide improved
services and acquire other grants. I certify that the information given above is true and complete to the best of my knowledge. I am signing knowing I am the designated representative of my whole household and this is the only application submitted for the members of this household. I understand that providing false or misleading information regarding anyone in my household is fraudulent and may be subject to criminal penalties.

By signing, I certify that I have read and understand the above agreement.
Applicant Signature*

Clear
Please verify that you are human*
Should be Empty:

Housing Assistance Application

Household Income Information

Vendor Information (Landlord, Utility Company)

Signature Page