Safe Overnight Parking Interest Form

1

Name* This field is required.

First Name

Last Name

2

Phone Number

Please enter a valid phone number.

3

Email

example@example.com

4

Preferred Method of Contact

Email

Phone

5

City of HomelessWhich city are you consistently residing in?

6

Briefly describe what events happened that led to you and your family living in your vehicle.

7

Enter the number of months you have been living in your vehicle?* This field is required.For example: 1 month = 1 | One Year = 12

8

Total Number of People in Your Household* This field is required.

9

Number of Adults* This field is required.Ages 18-59 years

10

Number of Seniors* This field is required.Aged 60+

11

Number of Minor Children* This field is required.Under 18 years

12

Is anyone in the household currently employed?* This field is required.

YESNO

13

Is anyone in the household currently receiving Social Security Benefits, Child Support, TANF or any other cash benefits?* This field is required.

YESNO

14

Total Monthly Income* This field is required.Including income from job(s), Social Security Benefits, Child Support, TANF and any other cash benefits. Enter 0 if none.

16

Is your driver license valid?* This field is required.

YESNO

17

Please explain why your license is not valid and what is needed to reinstate?

18

Is your car insurance current?* This field is required.

YESNO

19

Please explain why your car insurance is not current and what is needed to bring reinstate? * This field is required.

20

Vehicle Type* This field is required.

Car/Sedan

SUV

Van

Other

21

Does anyone in the household have any criminal charges that are violent or sexual in nature? Indicating "Yes" is not an automatic disqualifier, but will be screened on a case-by-case basis* This field is required.

YESNO