Housing Services Application

Acknowledgement

Applications will be held for one year. Re-application will be necessary after that period.
Please read the statements below and then sign/date.

I certify that the information given by me is true and accurate to the best of my knowledge.

I understand that there will be information exchanged between Ravenwood Health and the apartment management or landlord regarding my housing needs. This is being done with my approval.

I understand that the references listed by me may be contacted by Ravenwood Health.

I am willing to apply for entitements for which I may qualify (Section 8, SSI, SSDI, Block Grant Funds, PRC Funds, and/or other emergency funds).

I understand that as a housing applicant, the information I have provided on this application will be entered into HMIS (Homeless Management Information System) for the purpose of recording my housing needs adn placement, or non-placement into Ravenwood Health's Housing Services Programs.

By signing below I acknowledge that i have read and agree to all the above.
Applicant Signature

Clear
Spouse Signature

Clear
If application is being completed by a third party please list your name below.

First NameLast Name
Signature of Third party

Clear
Signature Date

MonthDayYear
Date
Should be Empty:

Housing History