Housing Inquiry

Housing Inquiry

Congratulations on taking a step toward housing and financial stability for your family. Please complete and submit this secure form. The information you provide will be used to determine if Family Renew Community has the right program for you.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email*
example@example.com
Are you a Volusia/Flagler County resident?*

YesNo
If so, for how long?
In what city are you currently living?*
Marital Status*

SingleMarriedDivorcedOther
Family Members Seeking Housing*

Single mother with childrenSingle father with childrenCouple with childrenOther
Which Family Renew Community residential campus would you prefer?*

Holly Hill (all families)Daytona Beach (single mothers)DeLand (all families)
For the remainder of this form, "you" refers to the person filling out the form. "Spouse" refers to the other adult in the family seeking housing, if any, regardless of marital status.
Are you pregnant?*

YesNo
If yes, what is the due date?
If you are single and pregnant, please call St. Peter's Visitation House: (386) 822-6014.
Is your spouse pregnant?

YesNo
If yes, what is the due date?
Spouse's Full Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Age
Are there children in your household under the age of 18?*

YesNo
Please list the genders and ages of all children in the household.*
Do you have custody of the children?*

YesNo
If no, please explain. Do you have a letter regarding unification?
Are you currently working?*

YesNo
If no, how long since you last had employment?
If not currently working, why did you leave your last job?
If yes, where are you currently working?
How long have you been with your current employer?
What is your current income from work?
Is your spouse currently working?

YesNo
If no, how long since they last had employment?
If your spouse is not currently working, why did he/she leave the last job?
If yes, where are they currently working?
How long have they been with their current employer?
What is their current income from work?
Have you ever been in a drug/alcohol treatment program?*

YesNo
If yes, when?
Where?
Type of program?

InpatientOutpatient
How long clean and sober?
Has your spouse ever been in a drug/alcohol treatment program?

YesNo
If yes, when?
Where?
Type of program?

InpatientOutpatient
How long clean and sober?
Have you ever been in a shelter/transitional housing?

YesNo
When?
Where?
Have you ever been arrested?

YesNo
If yes, have there been any felony arrests in the last three years?

YesNo
Please explain any felony arrests in the last three years. When? Where? Why?
A background check will be completed to verify the information you provide about arrests.
Has your spouse ever been arrested?

YesNo
If yes, have there been an felony arrests in the last three years?

YesNo
Please explain any felony arrests for your spouse in the last three years. When? Where? Why?
A background check will be completed to verify the information you provide about arrests.
Please list the amounts your household receives per month of any of the following:
All fields are mandatory. If it does not apply type 0 or N/A.
Food Stamps/SNAP*
TANF/Government Assistance*
Child Support*
WIC*
Child Tax Credit*
SSDI, SSI or SS benefits*
Please enter amount of monthly benefit, if any. DO NOT enter your ID number.
Briefly explain your current living situation.*
What if any person or agency referred you to Family Renew Community?
Should be Empty: