Wilder Direct Housing Assistance Program Application

2. Household Member Information

List Head of Household and all household members 18 years old and older.

List Head of Household and all applicants 18 years and older*

	Head of Household	Adult Family Member 1	Adult Family Member 2	Adult Family Member 3
Full Name
D.O.B.
Social Security #
Phone #
Email Address

Upload photo identification for all adult household members over the age of 18 years of age. *

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3. All Household Members

Add head of household and, ALL ADDITIONAL household members from birth to 99 years of age.
(click on the + to add the next household member)*

Wilder Direct Housing Assistance Program Application

Disclosure: Please note that your application will be shared with our evaluator, Wilder Research. The reason we share this information is to learn more about the people who receive Direct Housing Assistance. Wilder Research will combine data (such as your family's income and rent amount) across all applications; you will not be singled out in any manner and your individual data will not be shared in our report.
1. English Fluency

This information will be made available in alternative format upon request.
English Fluency: Interpreter/alternative format of this form requested*

No (Proceed to question 2)Yes (STOP- Contact our team at dha@wilder.org or 651-280-2430).
Primary Language:
SpokenWritten
Secondary Language:
SpokenWritten

4. Income for All Household Members

(Example of Source: Earned Income, MFIP, GA, Social Security, SSI Disability, Compensation, Alimony, Child Support, Pensions, Trust Funds, Annuities, Tribal Income, Income from Rental Property, and Armed Forces Reserves)*Please include proof of all sources of income for all household members.
Instructions: Identify your pay frequency and upload checkstubs accordingly. Please note that your application will not be processed without documentation of your income.

Paid Monthly: Upload one (1) check stub / proof of income document Paid twice a month (Example: 1st/15th): Upload two (2) checkstubs/ proof of income document Paid bi-weekly: Upload two (2) checkstubs / proof of income document Paid weekly: Upload 4 checkstubs/ proof of income document Paid daily: Upload 30 days proof of income for the time period worked
(click on the + to add the next household member, scroll to the right to complete all fields)*
Upload income/benefits verification for all household members that receive income/benefits. *

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Upload 2nd paystub/ income/benefits verification for all household members that receive income/benefits.

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	Address (Street Number, Street Name, City, Zip)	Move in Date	Move out Date	Loan # (required for mortgage)
Current Address

	Landlord/Mortgage Company Name	Street Number, Street Name, City, Zip	Phone Number	Email
Landlord/Mortgage Name, Address and Phone

6. Anticipated Moves During Subsidy Administration

*Please note all moves are subject to additional review process and, approval is at the discretion of the program administrators. Payments may not be transferrable to a different landlord or mortgage company.
6A. Do you anticipate moving at any time during the administration of program if you are accepted into the program?

No (Proceed to question 7)Yes (Proceed to question 6B)
6B. If you answered Yes: please provide a brief explanation and, anticipated moving date.

0/500

8. WILDER PROGRAM REFERRAL

Please provide the programs and services you currently participate in at Amherst H. Wilder Foundation. Please note that this is an eligibility requirement, SELECT THE PROGRAM THAT YOU ARE AFFILLIATED WITH.
Are you a current Wilder client/participant?*

No (Proceed to question 9)Yes (Proceed to question 8B.)
8B. (click on the + to add the next household member)*

9. WILDER KINSHIP REFERRAL- ONLY COMPLETE THIS SECTION IF YOU HAVE A KINSHIP REFERRAL.

Kinship Referrals Only– In order to have kinship eligibility you are required to have a family member enrolled and, receiving Wilder Services and approved for Direct Housing Assistance.
9A. Do you have a family member that is currently a Wilder client/participant and currently enrolled in DHA?

NoYes (Proceed to question 9B-9C.)
9B. Relationship to enrolled Direct Housing Assistance Participant

Parent( Mother/Father)Grandparent/sAdult ChildAdult Sibling
9C.

You're almost done!

Please read and sign the application below. All adults (18 years of age and older) must sign the application.
I/We understand:
- I/We understand:
  
  The information in this application will be used to determine eligibility for housing assistance and that this information will be verified.
  
  That withholding or supplying false information during the screening, or intake process will make all household members ineligible for housing assistance and the application will be denied.
I/We also certify that all information given in this application is true, complete and accurate.
Applicant Signature(s):*

Clear
Date:*

MonthDayYear
Date
Co-Applicant Signature

Clear
Date

MonthDayYear
Date
*In Office Use ONLY! Verbal Authorization-Completed App Over The Phone

Clear
Date

MonthDayYear
Date
Amherst H. Wilder Foundation Non-Discrimination Notice: The Amherst H. Wilder Foundation is committed to ensuring that all individuals have equal access to our programs, services and facilities without regard to race, color, ethnicity, language, national origin or ancestry, religion, gender, age, veteran status, political beliefs, mental or physical challenges, social economic condition or status with regard to public assistance, sexual orientation, gender identity, genetic information or medical history.

The Amherst H. Wilder Foundation combines knowledge, compassion and action to improve lives today and for generations to come. Wilder is a nonprofit community organization that creates lasting, positive change rooted in people through direct services, research and community building.

451 Lexington Parkway N., Saint Paul, MN 55444 | 651-280-2363 | wilder.org

Amherst H. Wilder Foundation: Supportive Housing Services
Wilder Direct Housing Assistance Program.

Should be Empty:

2. Household Member Information

3. All Household Members

Wilder Direct Housing Assistance Program Application

1. English Fluency

4. Income for All Household Members

5. Current Address Where You Live

6. Anticipated Moves During Subsidy Administration

7.Historical Subsidy Administration Information

8. WILDER PROGRAM REFERRAL

9. WILDER KINSHIP REFERRAL- ONLY COMPLETE THIS SECTION IF YOU HAVE A KINSHIP REFERRAL.

10. AMHERST H. WILDER SERVICE OPTIONS

You're almost done!