• Anishinaabe Endaad Program Application

    Anishinaabe Endaad Program Application

    This form is confidential and HIPAA compliant. Please complete the questions below so we can determine eligibility for our programs.
  • Today's date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Program Location(s)*

  • Helix is the housing support (GRH) service for provider for our Minneapolis locations. Please submit their referral form to apply.

  • Do you have children in your care?

  • Note:

    Anishinaabe Endaad is not able to provide services or housing for women with children.
  • How many are in your care that would be living with you?
  • Do you have any restrictions regarding being around children/minors?*
  • Requested move in date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Were you referred to the program?*
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  • Demographics

  • Veteran

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  • Okay to leave message?*

  •  -
  • Okay to leave message?

  •  -
  • Okay to leave message?

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*

  • Race (select all that apply)*
  • Enrolled Tribal Member?*
  • Descendant of a Tribe?*
  • Also a descendant of another Tribe?*

  • Income / Assets

    Please enter your income and assets for the past 30 days.
  • Currently Employed?*

  • Employment History
    Rows
  • Monthly Income*
    Rows
  • Assets*
    Rows

  • Criminal History

  • Do you have any evictions on your record?*

  • Do you have a criminal record?*

  • Do you have any sex offenses?*

  • Do you have to notify the community?*

  • Are you on probation or supervised release?*

  •  -
  • Do you have barriers to finding housing?*

  • Long-Term Homeless Verification

    Residents must meet the Minnesota definition for long-term homelessness

  • Households Experiencing Long-Term Homelessness (Minnesota): Individuals who lack a permanent place to live continuously for a year or more, OR at least four (4) times in the past three (3) years. Any period of institutionalization or incarceration shall be excluded when determining the length of time an individual has been homeless.

    • Doubled Up/Couch Hopping: Doubled up or couch hopping is considered an episode of homelessness if a person is doubled up with another household (and duration is less than one year) or couch hops as a temporary way to avoid living on the streets or an emergency shelter.
    • Transitional Housing: Time spent in transitional housing (TH) is a neutral event. Housing history prior to or after transitional housing should be evaluated to determine if it meets the state’s LTH definition. For example, if a household was homeless eight (8) months prior to entering TH and four (4) months after existing TH, the household would meet the LTH definition.
    • Exclude institutions and incarceration: Any period of institutionalization or incarceration shall be excluded when determining the length of time a household has been homeless.
  • During the past three (3) years have you been?*

  • Disability Information

  • Disabling condition*

  • Do you require special care, assistance, or special accommodations?*

  • Contact(s) Information

  • Person Completing Form*
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  • Signature Page

  • With my signature below, I certify that the information provided on this application is accurate and complete to the best of my knowledge and belief. I understand that false statements or information are punishable under Federal Law. I also understand that false statements or information are grounds for denial and termination of housing assistance and termination of tenancy. I understand that ANY changes to the application must be reported in writing to Anishinaabe Endaad property management within 10 days of the change.

  • Should be Empty: