Housing Assistance Application
Head of Household Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Social Security Number
*
Sex
*
Please Select
Male
Female
Race
*
Please Select
White
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
Black/African American
Unknown
Phone Number
*
Ethnicity
*
Please Select
Not Hispanic or Latino
Hispanic or Latino
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
example@example.com
Please select the valid forms of identification you have in your possession (Check ALL that apply)
Driver's license
State ID
Social Security Card
Birth Certificate
Green card/Work Permit
Do you have a legal guardian?
Yes
No
Have you been diagnosed with a mental illness or I/DD?
Yes
No
Have you been approved for a NC Innovations Waiver?
Yes
No
Have you been approved for 1915i?
Yes
No
Have you been approved and/or receive any of the following rental assistance subsidies/vouchers?
TCL
DASH Program
Rapid Rehousing
Section 8
Public Housing
HUD VASH
Other
Are you presently working with one the following community organizations:
CST (Community Support Team)
ACTT (Assertive Community Treatment Team)
Peer Support Specialist
TCL Peer Support
Community Navigator
None of the above
Household Size
Number of Adults in the household applying
Please Select
1
2
3
4
5
6
7
Number of Children in the household under age 18
Please Select
1
2
3
4
5
6
7
Do you have pets
*
Please Select
Yes
No
Income and Benefits
Do you currently receive any income
*
Please Select
Yes
No
Source of Income
Social Security
CLA Funds
Gov't Assistance
Veterans Benefits
Wages from employment
Retirement Income
Other
Total Monthly Income
Do you receive any of the following (Check ALL that apply)
Foodstamps
Medicaid
Medicare
Veterans Benefits
Supplemental Nutrition Program (WIC)
State Children's Health Insurance Program
TANF Child Care services
Housing Barriers
Are you currently experiencing any of the following
Unsheltered Homeless
Sheltered Homeless
Residing in an Adult Care Home/Facility
Residing in shared housing
Residing in Transitional Housing
Residing in a halfway house
Residing in a private residence
Can you obtain utilities in your own name
*
Please Select
Yes
No
Do you have any past due unpaid utilities
Yes
No
Are you experiencing any of the following credit challenges (Check ALL that apply)
Little to No Credit
Unpaid Collections
Past Evictions
Reposessions
Are you presently living in public housing or have a section 8 voucher
*
Please Select
Yes
No
Have you or additional applicant(s) ever been arrested for a misdemeanor or felony
*
Please Select
Yes
No
Are you or additional applicants presently using illegal controlled substances
*
Please Select
Yes
No
Are you or additional applicant(s) required to register as a lifetime sex offender in any state
*
Please Select
Yes
No
Housing Needs and Preferences
Housing Location Preference (Choose 3)
North Charlotte (Northlake, University Area)
East Charlotte (Plaza Midwood, Hickory Grove, Idlewild etc.,)
West Charlotte (Arbor Glen, Clanton Park, Oakdale, Paw Creek etc.,)
South Charlotte (Dilworth, Coltswald, Eastover, Madison Park etc.,)
Center City (Uptown, 1st Ward, 2nd Ward, 3rd Ward etc.,)
Other
Number of Bedrooms
1
2
3
4
Special Needs (Check ALL that apply)
Handicap accesible
Apartment
House
Close to Public Transportation
Please list any additional housing requests not listed above
Emergency Contact Information
Full Name
First Name
Last Name
Phone Number
Email
example@example.com
Please select a date and time available to complete the Housing Assesment Appointment
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
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