The Ihkam House – Intake Form
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Personal Information
Full Name
Date of Birth
*
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Month
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Day
Year
Date
Phone Number
*
Email Address
*
Current Address (Street, City, State, Zip)
*
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Housing & Referral Information
Desired Move-in Date
*
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Month
-
Day
Year
Date
Who Referred You? (Caseworker/Agency Name or “Self”)
*
Do you have a valid ID & Social Security Card?
Yes
No
Are you a U.S. military veteran?
*
Yes
No
Preferred Move-in Date
*
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Month
-
Day
Year
Date
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Eligibility Screening
Have you ever been convicted of a violent or sexual offense?
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Financial & Support Information
Monthly Income Source(s)
SSI
SSID
VA benefits
Employment
Other
Total Monthly Income
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References & Emergency Contact
Emergency Contact Name
*
Relationship to You
*
Phone Number
*
Reference #1 Name & Contact Info
Reference #2 Name & Contact Info
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Consent & Signature
Consent Statement: "I certify that the information I have provided is true and complete to the best of my knowledge. I understand that providing false information may result in my application being denied.
*
Yes
No
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Digital Signature
*
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Date Signed
Date Signed
*
-
Month
-
Day
Year
Date
Thank You for Applying!
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Thank You for Applying!
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