Northwest Indiana Structured Living InitiativeComprehensive Housing Program Application

1

Please complete all sections. Incomplete applications may delay processing.

2

Full Name:

3

Date of Birth:

Date

4

Phone Number:

5

Email Address:

example@example.com

6

Current Address:

7

City/State/ZIP:

8

Driver's License/State ID #:

9

Name Of Emergency Contact :

10

Relationship:

11

Phone Number:

12

Email:

example@example.com

13

Referral Agency:

14

Case Manager:

15

Phone:

16

Email:

example@example.com

17

Veteran Senior Former Foster Youth

Veteran

Senior

Former Foster Youth

18

Reentry Homeless At Risk of Homelessness

Reentry

Homeless

At Risk of Homelessness

19

Employed SSI SSDI VA Benefits

Employed

SSI

SSDI

VA Benefits

20

Employer/Income Source:

21

Monthly Income:

22

Other Sources of Income:

23

Current Living Situation:

24

Length of Stay:

25

Reason for Seeking Housing:

26

Supportive Services Requested

Employment Assistance

Life Skills Training

Transportation Resources

Education Assistance

Budgeting Assistance

Healthcare Referrals

27

Have you ever been convicted of a felony?

Yes

No

28

If yes, please explain:

29

Required Documents List

Government-issued ID

Proof of Income

Benefit Award Letter (if applicable)

Referral Letter (if applicable)

Birth Certificate

30

I certify that all information provided is true and complete. I understand that providing false information may result in denial of housing.

31

Applicant Signature:

32

Date:

Date

33

I authorize Northwest Indiana Structured Living Initiative to verify information contained in this application and communicate with referral agencies regarding housing eligibility.

34

Applicant Signature: