Motel to Home Application

SOCIETY OF ST. VINCENT DE PAUL

MOTEL TO HOME APPLICATION
Date

MonthDayYear
Date
PERSONAL INFORMATION
Name

First NameLast Name
Current Hotel
Hotel Address
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Format: (000) 000-0000.
MarriedSingleDivorcedWidowed
Others Living with You (Name, Age, Relation)
RESIDENCY HISTORY
Prior to living in extended stays/motels, where did you live?
0-90 Days3-6 Months6-12 Months1-2 Years3+ Years
Have you been evicted? If so, how many times?
Do you have unpaid rent or utility bills in your name?
FINANCIAL INFORMATION
What is your current credit score? (Estimate)
Do you have regular income from any of the following types of employment?
Full Time? If so, how long have you had this job?
Part Time? If so, how many jobs? How long have you had each of these jobs?
Seasonal?
Are you currently receiving Social Security or Disability?
Are you currently receiving Child Support?
Are you currently receiving SNAP (Food Stamps)?
What is your monthly household income (Including all income, employment, SSDI, Child Support, etc.)?
What do you pay each month at the motel/extended stay?
Do you have a checking account?
Do you have financial debt (loans, car, credit cards, etc.)?
OTHER
Have you ever been convicted of a felony?
Have you ever been convicted of a misdemeanor?
Are you currently on probation?
Are you currently on parole?
Do you have a working car?
PROGRAM AGREEMENT
Are you willing to?
Work one-on-one with a member of St. Vincent de Paul?
If necessary, attend workshops on budgeting, financial counseling, etc.?
Complete periodic surveys, to assess your housing progress?
SIGNATURE
By signing, the applicant represents that all of the above information is true and correct and hereby authorizes verification of the above items, including, but not limited to, the obtaining of a credit report or background check. If any information is false, Society of St. Vincent de Paul-District Council of Richmond is entitled to reject the application.
SignatureDate

Clear
Should be Empty:

SOCIETY OF ST. VINCENT DE PAUL

PERSONAL INFORMATION

RESIDENCY HISTORY

FINANCIAL INFORMATION

OTHER

PROGRAM AGREEMENT

SIGNATURE