Housing Assistance Application Form

Humanity In Progress

Housing Assistance Application

Humanity In Progress' funding focus is to keep people housed and get unhoused into new housing in Petersburg, Alaska. We will not pay more than the amount owed on any account. All payments are made directly to the vendor (landlord or utility company). Please complete the application with as much information as possible to expedite the process. Due to limited funding, we are not able to fund all requests.

Applications received between the first and the 15th of the month will be reviewed by the 25th, and applications received between the 16th and end of the month will be reviewed by the 10th of the following month.

Applications Submitted between:	Reviewed by:
1st-15th of the month	25th
16th-end of the month	10th of the following month

Humanity In Progress is run solely by volunteers. Thank you for your patience in this process.

Humanity In Progress

Housing Assistance Application
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*
application status will be emailed
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:*

Rental AssistanceDeposit AssistanceUtility Assistance
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 and how you plan to pay future housing costs.
Vendor Information (Landlord, Utility Company)

Payments will be sent directly to vendor
Vendor *
Who do we need to pay?
Account Number
i.e. Utility account number
Vendor Phone Number
Vendor Email
Landlord Email
Vendor Address to Mail Check*

Mailing Address

CityState

Zip Code
Amount Requested*
Minimum amount needed*
Amount needed to prevent homelessness/utilities shut off.

Humanity In Progress

Housing Assistance Application
I, First Name Last Name authorize the release of information from my rental/utility vendor Rental/Utility Vendor* to Humanity In Progress (HIP) and further authorize HIP to communicate with 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*
Date *

MonthDayYear
Date
Should be Empty:

Humanity In Progress

Humanity In Progress

Household Income Information

Vendor Information (Landlord, Utility Company)

Humanity In Progress