Trinity Arms Housing Application

Trinity Arms Housing Application
Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Alias:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Place of Birth:
Are you currently enrolled in another program?
If yes, explain.
Apartment Size?
Are you DV or Reentry?
Gender

Other
Ethnicity
Marital Status
US Citizen?
If no, what is your Immigration Status?
Are you currently empolyed?
Current or Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at this address?
Is this address permanent or temporary?
Is this address a shelter or family members?

Other
Case Manager Contact

Case Managers will be contacted as part of the application process.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Agency
Email
example@example.com
Homelessness

If homeless, please complete the following
Are you currently homeless?
How did you become homeless?
Is this your first time being homeless?
Date you became homeless

MonthDayYear
Date
Reason for leaving prior housing?
Name of Shelter/Institution you've stayed?
Have you ever been evicted?
If yes, Date of eviction?

MonthDayYear
Date
Information on Children

You are required to have children to qualify.
Do you have children?
Are they living with you?
Do you have custody of your children?
If no, please explain.
Is there contact with both children's parents?

Do you have children that are not living with you?
If yes, why?
Do you have an open child abuse or neglect cases?
If yes, why and how long has your case been open?
Medical History

This does not make you ineligible for housing assistance.
Do you have insurance?
Current Heath Provider

Other
Is the insurance in your name?
If no, please provide name of Primary Insurer:
If disabled, please list you and your family member's disabilities:
Mental Health History

This does not make you ineligible for housing assistance.
Have you been hospitalized for an emotional or mental condition?
If yes, explain:
Have you received treatment and/or medication for emotional/mental condition?
If yes, explain:
Substance Use History

This does not make you ineligible for housing assistance.
Have you ever used drugs or alcohol?
If yes, what is your substance of choice and how often did you use?
Ever been treated for any addiction?
If yes, explain:
AA/NA/GA attendance?
If yes, where?
Do you have a sponsor?
Estimated last date of alcohol/drug use?
Legal History

This does not make you ineligible for housing assistance.
Have you been arrested before?
Is there currently a warrant out for your arrest?
Have you ever been convicted of a crime?
Have you ever served jail/prison time?
If yes to any questions above, please explain and list previous arrest record.
Are you on probation or parole?
If yes, give probation or parole officers name, phone number and the date it ends.
References

References will be contacted as part of the application process.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship:
Completion of this application does not guarantee housing or supportive services.
Signature
Should be Empty:

Rows	Childs Name	Date of Birth	School Attending	Any Disabilities, Y/N?
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Trinity Arms Housing Application

Case Manager Contact

Homelessness

Information on Children

Medical History

Mental Health History

Substance Use History

Legal History

References

Completion of this application does not guarantee housing or supportive services.