Housing Stability Application
Applicant Information
Head of Household
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Gender
Please Select
Male
Female
Other
Prefer not to answer
Do you have a disability?
Yes
No
Are you a veteran?
Yes
No
Household Information
Total number of adults (age 18+) in the household:
Total number of children in the household
Total number of household members:
Monthly household gross income:
Address or Current Living Situation
What county are you residing in?
Please Select
Buffalo
Clark
Eau Claire
Jackson
Trempealeau
Other
Resident Address
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently renting?
Yes
No
Are you currently facing an eviction?
Yes
No
Have you recently been evicted?
Yes
No
Current living situation:
Renting
Staying at a shelter
Living in a vehicle
Sleeping outside
Couchsurfing (staying with family or friends)
Hotel or motel
Other
Services
What current services are you receiving? Check all that apply:
*
FoodShare
BadgerCare (Medicaid)
Section 8
WIC (Women, Infants & Children)
Unemployment
Social Security
Eau Claire City Housing Authority
Eau Claire County Housing Authority
Other City/County Housing Authority
TANF (Temporary Assistance for Needy Families)
Peer support services
Other
What services are you interested in?
*
Housing Navigation
Housing Stability Case Management
Eviction Prevention
Housing Counseling
Landlord Mediation
Fair Housing Counseling
Legal Services Referrals
Budgeting Assistance
Employment Counseling
Additional Specialized Services
Submit
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