LHC Housing Services Application UPDATE form

THIS IS NOT AN APPLICATION FOR
HOUSING SERVICES

Please DO NOT fill out this form if you have not already submitted a full Housing Services application. This form is only to update your existing information. If you submit this form without having an active application on file, it will NOT be processed.

Please only use this form to update any pertinent information for applicants already on the Housing Services waitlist.

EQUAL HOUSING OPPORTUNITY- Laurel Hill Center’s housing is program housing specifically for individuals who meet eligibility criteria for LHC services and participate in its programs. LHC complies with the Fair Housing Act. The information on this sheet will help us find you the best possible program or assistance for your situation.

YesNo

Housing applications are only accepted for individuals who are actively engaged in Laurel Hill Center Behavioral Health services.

If you are an active client and are interested in applying for Housing Services, please see your case manager for an original application.

YesNo

Applicant's Name*

First NameLast Name

Date of Birth*

Date

Gender

Pronouns

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Complete Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PhoneEmailOther

YesNo

Describe the nature of the requested accommodation:*

YesNo

Additional Household Members: (List any and all additional people (if any) who will be living with you)

Rows	Name	DOB	Gender	Relationship
Person 1
Person 2
Person 3
Person 4

YesNo

Who are you working with at Laurel Hill Center? (Case Manager)*

SSI/SSDIWages from EmploymentNo IncomeOther

Total monthly household income*

Payee Name (if applicable)

First NameLast Name

Payee Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

*By providing payee information and signing this application, you authorize LHC to contact your Payee regarding security deposits, rent, or other financial requirements for LHC’s Housing Programs.

I am literally homelessI am at serious risk of becoming homelessI live in time-limited housing such as a housing program that is not meant to be permanent or is considered "transitional"None of the above definitions apply to my current housing situation

★ By signing this application update form, I understand that I will be placed on a waiting list. Applicants will be prioritized according to established contract requirements, policies, and procedures. I also understand that it is my responsibility to contact LHC should my contact information, household composition, or eligibility information change. Failure to do so may result in loss of opportunity to apply for housing assistance or denial of housing assistance due to household or eligibility changes.

CERTIFICATION: The information provided on this application update form is complete and true to the best of my knowledge. I understand that providing false information may lead to denial of this application, to termination of rental agreement (if falsehood is discovered after move-in), or to criminal prosecution. I understand that admission is conditioned upon eligibility criteria set by state law, this site’s Tenant Selection Plan, and my payment of applicable rent and security deposit in advance of move-in. I understand that, should I be accepted for admission, I must not maintain any other residence anywhere after I move in. I further understand that this information will be verified and that I must keep the application current by notifying Laurel Hill Center of changes in address and preferential status.

Name*

Today's Date*

Date

LAUREL HILL CENTER