Offering Room Affordable Living for the Aging

Housing Provider Application

This application takes 15 to 20 minutes to complete.
This project is funded in part by L.A. Care Health Plan and will benefit low-income and uninsured residents of Los Angeles County
Disclaimer

Staff may need up to 5-7 working days to review your application. If you need urgent housing assistance or other related resources, please click here: Los Angeles County Housing and Housing Subsidies

If you need assistance completing the form, click here to send us a message or call (747)-334-2301
Housing Provider Minimum Requirements
- You are a current resident of Los Angeles County
- You have a private bedroom available for rent
- You have never been convicted of a crime
Please Note:

A $17 payment is required for a background check. We will send the payment request after your interview.
Please select all that apply

I am a current resident of Los Angeles CountyI have a private bedroom available for rentI have never been convicted of a crime
To be eligible for our program, you must meet all of the following criteria. If you have any questions, please don't hesitate to send us a message.*

I certify that I meet all of the above criteria and understand that a $17 payment will be required for a background check.

Background Information
Full Name
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Email**
Phone Number*
Please enter a valid phone number.
What is your preferred method of contact?

CallTextEmail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you resided in California?
Why have you decided to share your home?*
Examples: extra income, companionship, help with household tasks
If you're experiencing difficulty uploading documents,
click here to send us a message.
We are here to assist you!
Application Assistance

Check this box if you need assistance uploading your documents. You can proceed with submitting your application without uploading them for now, and we will assist you during your interview.
Upload One Form of Identification*

Example: Driver's License, Passport, Permanent Resident Card, Military ID, etc.
Cancelof
What is your current monthly income?*
Please round up to the nearest whole number. Do not include $ symbol.
Please provide two references

REFERENCE #1
R1 Name*

First NameLast Name
R1 Phone Number*
Please enter a valid phone number.
R1 Email
example@example.com
REFERENCE #2
R2 Name*

First NameLast Name
R2 Phone Number*
Please enter a valid phone number.
R2 Email
example@example.com
To SAVE & CONTINUE later, follow these steps:
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2. The screen will dim or go dark—this is normal.
3. Scroll to the top of the page.
4. Click “Skip Create an Account.”
5. Choose one of the following options:
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    (Make sure to save this link somewhere safe—you’ll need it to return to your draft.)

Additional Questions

If you are experiencing issues or have questions,
click here to send us a message.
We are here to assist you!
How did you hear about our Shared Housing program?**

Internet searchReferral/word of mouth/organizationSocial mediaNews sourceOther
If Referral, please list organization or individual
If Other, please explain
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Name*
Emergency Contact Relation*
Examples: Son, daughter, cousin, close friend
Waiver and Indemnity Agreement
Affordable Living for the Aging ("ALA") works to bring together persons who are in need of housing. This Waiver and Indemnity Agreement ("Agreement") applies to placement in an ALA-facilitated home-sharing arrangement ("The Program").

ALA does not discriminate on the basis of race, religion, color, national origin, ancestry, marital or veteran status, physical or mental disability, medical condition, genetic information, sex (including breastfeeding and related medical conditions), gender, gender identity, gender expression, age, or sexual orientation, or any other protected characteristic under federal, state, or local law.

ALA is not the agent of any party, but simply acts as a facilitator who provides the opportunity for the parties involved to come together for the purpose of shared housing. The decision to enter into a home-sharing arrangement resides with the program participant. The decision to occupy an ALA-rented unit resides with the applicant.

ALA does not provide any express or implied guarantee of the suitability or success of the home-sharing arrangement. Individuals who apply for and participate in the Program should explore any potential impact shared housing rental income may have on their taxes and/or benefits, prior to sharing. These individuals also should explore any potential impact shared housing may have on their current rental agreement or lease, including obtaining the landlord's approval, if necessary.

In consideration of the foregoing, I agree to indemnify and unconditionally release ALA, and each and all of ALA's Board of Directors and Trustees, owners, predecessors, successors, assigns, agents, directors, officers, employees, former employees, representatives, attorneys, accountants, benefit plans, insurers, parent companies, divisions, subsidiaries, affiliates, and all persons acting by, through, or under or in concert with any of them (collectively "Releasees") from any and all individual, class, and/or representative claims, causes of action, losses, demands, complaints and liabilities (including but not limited to attorneys' fees) of any kind whatsoever against the Releasees, relating to my application for, participation in, or termination from the Program, including, without limitation, any and all individual, class, and/or representative claims of any kind whether caused by negligence or otherwise.

I understand that any false statements or misleading information may result in disqualification from or consideration for the Program. I understand that my application and authorization for participation in the Program does not guarantee housing and does not guarantee housing within any specific time period. I acknowledge and agree that I carefully read and considered this Agreement, that I fully understand it, and that I sign this Agreement knowingly and voluntarily, with the intent to be legally bound by its terms.
Signature

Clear
Required Interview

After clicking the ‘Submit’ button below, you will be directed to a calendar. Please choose a day and time for a 30-minute meeting with our staff. Without an interview, you cannot be considered for matching.
Background Check

If you are experiencing issues or have questions,
click here to send us a message.
We are here to assist you!
I hereby authorize ALA to obtain consumer credit reports and investigative consumer reports about me in connection with the
hiring of a dwelling unit, as defined in subdivision (c) of Section 1940 of the California Civil Code, and/or for legitimate business
needs in connection with a business transaction with which I am involved. I understand that ALA and its agents are not responsible
for the accuracy or completeness of the information contained in any such reports.

TO THE FULL EXTENT PERMITTED BY LAW, I HEREBY RELEASE ALA AND ITS AGENTS FROM ALL LIABILITY AND CLAIMS
RELATING TO THE INFORMATION OBTAINED FROM ANY AND ALL SOURCES IN CONNECTION WITH SUCH REPORTS.

I acknowledge that a fax or copy of this Notice and Authorization bearing my signature shall be as valid as the original for all
purposes. This Notice and Authorization is valid for all federal, state, county, and local agencies and authorities, and for all public
and private sources that maintain records concerning my past activities. I further acknowledge that I have received a copy of “A
Summary of Your Rights under the Fair Credit Reporting Act” and any notices required under the California Consumer Credit
Reporting Agencies Act and the California Investigative Consumer Reporting Agencies Act.

I understand that this authorization is not a guarantee for housing and does not guarantee housing within a specified time period. I
certify that the information on this form is true and correct. I understand that any false statements or misleading information may
result in disqualification from or consideration for ALA’s housing programs.

I understand that the $17 fee is non-refundable, regardless of acceptance into the program.
We require background checks to ensure the safety of our program participants.*

I authorize and confirm understanding of the items mentioned above.
Date of Birth*

MonthDayYear
Date
Driver License # / State
SSN**
You have the right to obtain a copy of any consumer credit or investigative consumer report obtained by ALA. To request a copy, check the box.
To SAVE & CONTINUE later, follow these steps:
1. Click the Save & Continue button below.
2. The screen will dim or go dark—this is normal.
3. Scroll to the top of the page.
4. Click “Skip Create an Account.”
5. Choose one of the following options:
  - Enter your email to send the draft to yourself, or
  - Click “Get Draft Link” to generate a unique link.
    (Make sure to save this link somewhere safe—you’ll need it to return to your draft.)
Should be Empty:

Housing Provider Application

Background Information

Waiver and Indemnity Agreement