Mae’s Loving Arms, LLC Application Form
Mae’s Loving Arms is a housing-only organization dedicated to providing safe, respectful, and structured shared living environments for adults seeking stability and a fresh start. We honor Mae’s life and legacy by offering housing that promotes security, independence, and peace of mind. We serve: Elderly Adults with intellectual or developmental disabilities (IDD, Adults with physical disabilities who can independently complete activities of daily living ADLs), Veterans in need of transitional support, and Returning citizens (re-entry population). Mae’s Loving Arms provides housing only and supports each resident’s right to choose any qualified third-party provider for services they may need.
Applicant Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Address
Street Address
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Referral Agency
Marital Status
Single
Married
Divorced
Sex (as listed on legal identification)
Male
Female
Prefer not to disclose
Are you a Convicted Felon?
Yes
No
“Do you understand that this home is for single residents only, with one resident per bed and per lease?”
Yes
No
“Are you requesting housing for anyone other than yourself?”
Yes
No
Current Living Situation
Homeless/Shelter
Staying with family or friend
Hospital/Treatment Facility
Correction/Re-entry placement
Other
“Requested Move-In Date:”
-
Month
-
Day
Year
Date
Proof of Income
Income & Employment Information
SSI
SSDI
Employment
Veterans Benefits
SNAP benefits
“Are you able to provide proof of income?”
Yes
No
Employment/Income Proof
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Employment Letter, Two Months Pay Stubs, etc.
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Are you able to pay a one-time, non-refundable deposit?
Yes
No
What are your payment plan for rent?
Weekly
Bi-weekly
Monthly
What Payment Method do you plan to use?
Cash
Zelle
Venmo App
Square Cash App
Paypal
Google Pay
Other
“Do you receive any assistance with daily activities (such as cooking, cleaning, hygiene, etc.)?”
Yes
No
“Are you able to live independently without daily assistance?”
Yes
No
“Do you understand that housing is provided in a shared room only?”
Yes
No
“Do you require transportation assistance?”
Yes
No
“Do you have your own vehicle?”
Yes
No
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Do you have a vaild identification card (ID, Passport, or Driver Licensed)?
Yes
No
ID or Driver license:
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Choose a file
Cancel
of
“Do you understand that Mae’s Loving Arms is a shared independent living housing environment, and that by entering this independent living housing agreement, you are agreeing to participate in a structured, supportive setting designed to help you build stability, independence, and healthy routines?”
Yes
No
Signature
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