NHDC Cares Pre-Screening Form
Important: Please do not call the office repeatedly, as it slows down our ability to process applications for everyone. Thank you for your patience and understanding. This is a pre-screen only and you will be notified requesting more information. We assist on a basis of date, time & score. Please continue to look we will notify you with either a decline with resources or a longer application to fill out to determine eligibility based on grant funding. Thank you for your patience.
Name
*
First Name
Last Name
Your Date of Birth
*
Your Social Security Number
*
Who referred you or how did you hear about our program:
*
Referral Source
What county do you reside in?
*
Please Select
Alachua County
Marion County
Dixie county
Union County
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Total monthly income Amount
*
Total
Current Monthly Rent Amount
*
How many bedrooms is your unit?
*
How many people are in your household?
*
Which of the following housing situations apply to household? (check all that apply)
*
Living in Rental with a housing that is being condemned by a government agency and tenants are being forced to move out.
Notified that right to occupy their current housing or living situation will be terminated within 21 days after date of application
Living in the home of another person because of economic hardhip
Living in hotel or motel and cost is not paid for by charitable organization or government program for low income people.
Recently exited a publicly funded institution or system of care.
Currently experiencing domestic violence and fleeing unsafe situation
None of the above apply
Number of times you have been literally homeless in the past 3 years:
*
Number of court-ordered eviction in past 3 years:
*
Risk Factors and Barriers (check all that apply):
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Eviction History
Lack of rental history (has not rented in the past)
Poor credit history
Critical Felony
Pregnant or at least one child under the age of 18
Head of household under 24 years old
Only one adult in household that include minor children
In the past what agencies have you received help from in the last 2 years (this will be verified).
*
Are you applying for rent, power and/or mortgage assistance?
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Rent
Power
Mortgage Assistance
How much total are you requesting?
*
Please describe your situation in detail AS TO WHY YOU CANNOT PAY YOUR BILL.
*
Submit
Should be Empty: