Application for Residency

Application for Residency

Please answer all of the following information to apply for residency at Marguerite's Place. Some questions are required by our funders, however all of your personal information will be kept anonymous.
Applicant Information
Date of Application:*
Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Is it safe for staff to leave you a voicemail?*
Which most accurately describes your race?*

Black/African AmericanWhite/CaucasianAmerican Indian or Alaska NativeAsianNative Hawaiian and Other Pacific IslanderOther
Do you identify as Hispanic or Latino?*
Primary Language:*
Applicant age:*
Date of Birth:*
Social Security Number:*
Referred by:*
Family Information
How many children do you have?*

Children Information*

	Name	Date of Birth	Age	Gender	Custody (Full/Share/None)	Social Security Number
Child 1
Child 2
Child 3
Child 4

Do you have a parenting plan in place?*
Do you have at least 50% custody of your children?
We may request custody court orders for verification
Have your children ever been enrolled in childcare?*
If yes, where?
Are your children currently enrolled in childcare?*
If yes, where?
Have your children ever witnessed or experienced abuse?*
Do you have any particular concerns about your children's development? If yes, please elaborate:*
Are you currently pregnant?*
If yes, what is your expected due date?
Income Information
Are you authorized to work in the US?*
Are you currently working?*
If yes, where?
What are your income sources? Check all that apply. To participate in our program, you must have a source of income*

EmploymentChild SupportFood StampsWorker's CompAlimonyUnemploymentAPTD Aid to the Permanently and Totally DisabledTANF Temporary Assistance for Needy FamiliesSSI Supplemental Security IncomeSSDI Social Security Disabilities InsuranceOther
Income from Employment
Income from Food Stamps
Income from Alimony
Income from APTD Aid to the Permanently and Totally Disabled
Income from SSI Supplemental Security Income
Income from Child Support
Income from Workman's Comp
Income from Unemployment
Income from TANF Temporary Assistance for Needy Families
Income from SSDI Social Security Disabilities Insurance
What is your combined monthly income from all income sources?*
Personal Information
Tell us briefly about your current housing situation, what caused this and why you are in need of transitional housing at this time. Share with us some of your short term and long term goals and how you would feel supported in our program as you work toward achieving these goals. Please provide any additionals details you would like us to know as part of your appplication*
Have you ever lived in a Transitional Living Program or Housing Program?*

If yes, please list programs and length of stay:

	Program Name	Length of Stay
Program Name
Program Name
Program Name

Do you have a history of substance use?*
If yes, what is your length of sobriety and what supports do you have in place to help you maintain your sobriety?
Have you ever been convicted of a crime?*
If yes, what was the conviction?
At any point in your life, have you experienced or witnessed violence?*
Have you struggled with mental health challenges in the past?*
If yes, have you engaged with any supports such as counseling or a support group?
Marguerite's Place Transitional Housing Program requires active and willing participation in case management, goal setting and planning for next step housing security and family stability.

By signing and submitting this apllpication, you are ackowledging understanding of our program model.
Signature

Clear
Thank you for applying for housing with Marguerite's Place.

Staff of Marguerite's Place will contact you to confirm receipt of this application. We keep a waitlist for our apartments and will process applications in order of receipt when an apartment becomes available. If you have any questions about the status of your application, please contact Director of Programs Candace Gordon at cgordon@margueritesplace.org or 603-598-1582 x 14.
Should be Empty:

Application for Residency

Applicant Information

Family Information

Income Information

Personal Information

Thank you for applying for housing with Marguerite's Place.