MiAH Application Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Total number of people living in your home.
Name of Significant Other living with you (if applicable).
First Name
Last Name
Number of children living in your home.
Child 1
First Name
Age
Child 2
First Name
Age
Child 3
First Name
Age
Child 4
First Name
Age
Type of dwelling
Apartment
Condo
Town Home
Single Family Home
Mobile Home
How long have you lived at this address?
Years/Months
How long have you lived in Colorado Springs?
Are you willing to have someone visit you and evaluate your furniture needs?
Yes
No
Maybe
If No or Maybe, please explain.
How did you hear about MiAH?
Facebook
Friend
Previous Client
Referred by Caseworker
If referred by caseworker, who and which agency?
Have you applied to other assistance programs?
Yes
No
If yes, which one(s)?
Have you applied to MiAH before?
Yes
No
If yes, what name did you apply with?
Do you have documented and verifiable source of income?
Yes
No
Have you had any felony convictions in the last 5 years?
Yes
No
If yes, please explain.
What circumstances led you to apply for assistance from MiAH?
If selected, how will this help you?
What is your most pressing need?
How did you access this application?
MiAH website
Facebook
Save
Submit
Should be Empty: