Intake application and consent

CLIENT INTAKE APPLICATION FOR ASSISTANCE

Beahive Affordable Housing Outreach, Inc. is committed to helping individuals and families secure stable housing. Please complete the following application to be considered for assistance. All information provided is confidential and will be used to determine eligibility and for demographic reporting purposes.

Beahive is a need-based program, not income-based. Approval notice will be sent via email and is not valid without written approval from Beahive Affordable Housing Outreach, Inc. All approved applicants will be required to attend a virtual financial literacy class as part of their participation.
Full Name
Date of Birth

MonthDayYear
Date
Phone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Method
Household Size

SECTION 3: FINANCIAL INFORMATION
Sources of Income (Check all that apply.)

EmploymentSocial Security/ DisabilityUnemploymentChild SupportPublic AssistanceOther
Note: Beahive Affordable Housing Outreach, Inc. is a need-based program, and your income level will not affect your eligibility. This information is collected for grant reporting purposes
Monthly Income Amount

SECTION 4: ADDITIONAL SUPPORT AND SUSTAINABILITY
What is your plan to ensure that this situation does not occur again?
Are there any other resources you may need to help increase your sustainability? (Check all that apply.)

Employment AssistanceChildcareFood AssistanceBehavioral Health ServicesLegal ServicesRe-entry AssistanceOther
Photo IDs for all household members over 18:

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Birth certificates of all household members under 18.

Cancelof
Copy of Lease:

Cancelof
Copy of Intent to Evict/Eviction Notice/Judgement

Cancelof
Documentation for application fee:

Cancelof
Delinquent Home Tax Information:

Cancelof
House Deed (must match photo id name and address:

Cancelof
Other:

Cancelof
Other:

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SECTION 5: ACKNOWLEDGEMENTS AND AGREEMENTS
I understand that this application is for assistance and that approval is based on a need assessment conducted by Beahive Affordable Housing Outreach, Inc. I acknowledge that I will be notified via email if my application is approved, and no approval is valid without written confirmation from Beahive Affordable Housing
I agree to attend a required virtual financial literacy class as part of the program if I am approved. I certify that all the information I have provided is accurate and complete to the best of my knowledge.
Signature

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Date

MonthDayYear
Date Received

MonthDayYear
Reviewed By:

First NameLast Name
Approval Notification Sent:

MonthDayYear
Date
Date of Financial Literacy Class

MonthDayYear
Date

CLIENT CONSENT TO CONTACT THIRD PARTIES
Client Name
Date of Birth

MonthDayYear
Date
Phone Number
Beahive Affordable Housing Outreach, Inc. is dedicated to providing housing assistance to those in need.

To offer and approve the requested aid, it may be necessary for us to contact individuals, agencies, landlords, or organizations that are involved in your housing or related services.

By signing this consent form, you authorize Beahive Affordable Housing Outreach, Inc. to contact the necessary third parties to verify information, process applications, or make approvals related to your request for assistance.

I hereby authorize Beahive Affordable Housing Outreach, Inc. to contact the following individuals, agencies, or organizations if necessary:
Current Landlord or Property Manager
Relationship/Role
Phone Number
Please enter a valid phone number.
Email
example@example.com
This consent allows Beahive Affordable Housing Outreach, Inc. to: I'm

Communicate with third parties regarding your housing situation and assistance needs. Verify information relevant to your application, including financial, housing, and personal

- Provide or obtain information necessary for the approval of your housing assistance.
This consent is valid for one year from the date of signing or until the housing assistance process is completed, whichever comes first. You may revoke this consent at any time by providing written notice to Beahive Affordable Housing Outreach, Inc.

Confidentiality:

Beahive Affordable Housing Outreach, Inc. is committed to protecting your privacy. All communications and information shared under this consent will be treated confidentially in accordance with applicable laws and regulations.

Client Acknowledgment:

I understand the purpose of this consent form and voluntarily agree to the terms outlined above. I have the right to ask questions and seek clarification before signing.
Client Signature

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Date

MonthDayYear
Date
Should be Empty:

SECTION 3: FINANCIAL INFORMATION

SECTION 4: ADDITIONAL SUPPORT AND SUSTAINABILITY

SECTION 5: ACKNOWLEDGEMENTS AND AGREEMENTS

CLIENT CONSENT TO CONTACT THIRD PARTIES