Housing Help Intake Application
The Junction Coalition 419 Junction Ave. Toledo, OH 43607
Note:
Thank you for reaching out to us in regards to your housing needs! Our housing program operates in three phases. You will enter Phase 1, as an “applicant” by completing this form. Phase 2: Active Inquiry, when we begin looking to fund your project, does not begin until you submit the necessary paperwork and identification, and the Housing team moves you to the Active Inquiry List; only persons with complete paperwork will be moved from the Active Inquiry Waitlist to Phase 2. Phase 3: Active Case, begins when funding and labor for your project is secured, and we begin the work. If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about housing counseling, please talk to your housing counselor about arranging alternative accommodations.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date (MM/DD/YYYY)
When is the best time to reach you?
What kind of housing assistance are you seeking (desired repairs, requests, etc.)?
Please indicate your gender
Male
Female
Non-binary
Prefer Not to Say
Ethnicity
Hispanic
Non-Hispanic
Race
Indian/Alaskan Native
Asian
African-American
Native Hawaiian/Pacific Islander
Caucasian/White
Biracial or Multiracial
How did you find out about us?
Word of mouth
Member of Staff
Website search
Social media
Bank or Mortgage servicer
Family/Friend
Religious or Social Org
HUD
Other
Are you disabled?
Yes
No
Are you a Veteran?
Yes
No
Are you a U.S. Citizen?
Yes
No
Marital Status
Single
Divorced
Married
Widowed
Separated
Household Size
Estimated Household Income (Gross)
Do you own your home?
Yes
No
Do you have housing insurance?
Yes
No
Submit
Should be Empty: