Grace Haven by AveXa- Housing Application
Who is completing this form?
Applicant
Social Worker/ Case Manager
Family Member/ Friend
Other
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name
Emergency Contact Phone
Monthly Income
Source of Income?
SSI (Supplemental Security Income)
SSDI (Social Security Disability Income)
Retirement Pension
W-2 Income
Other
If other, please explain below.
Do you have a criminal record?
Yes
No
If yes, please explain below.
Where are you currently living?
With family/ friends
Shelter
Transitional housing
Other
Are you able to manage your daily needs without assistance?
Yes
No
If no, please explain below.
What is one thing you want to accomplish within the next 12 months?
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: