Plant a Purpose Intake Application
Applicant Information
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name / Nickname
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Gender Identity
SSN Last 4 Digits
Phone Number (Cell)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Government-Issued Photo ID Please upload copy below:
Florida Driver's License
State-Issued ID
Passport
Other
File Upload
*
Browse Files
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Emergency Contacts
Emergency Contact 1 - Full Name
*
First Name
Middle Name
Last Name
Emergency Contact 1 - Relationship to Applicant
*
Emergency Contact 1 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 1 - City / State
Emergency Contact 2 - Full Name
*
First Name
Middle Name
Last Name
Emergency Contact 2 - Relationship to Applicant
*
Emergency Contact 2 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 - City / State
Residential History and Housing Need
Reason for Leaving Most Recent Residence
*
Please list the City and States You have lived in for the past 7 years:
Requested Move-In Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Intended Length of Stay
Why are you seeking shared housing at this time?
*
Income and Employment
Current source of income or financial support
*
Full-time employment
Part-time employment
Self-employment / freelance
SSI
SSDI
Other public benefits
Other
Income Source - Other
Employer Name
Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Job Title / Position
Employment Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Monthly Gross Income
If not currently employed - Source of financial support
If not currently employed - Monthly amount available for housing
Please Upload Proof of Income Pay Check, Bank Statements, Award Letters:
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Documentation provided
Pay stubs
SSI / SSDI award letter
Bank statement
Employer verification letter
Sponsor / guarantor letter
Other
Documentation - Other
Background and Legal History
Ever been evicted or asked to leave a housing situation?
*
No
Yes
Eviction explanation
Ever been convicted of a felony?
*
No
Yes
Felony explanation
Currently on probation or parole?
*
No
Yes
Probation/parole officer or agency name and phone
Current or pending legal matters that may affect housing?
*
No
Yes
Legal matters explanation
Support Services and Emergency Information
Currently under care of caseworker / case manager / counselor / social worker?
*
No
Yes
Agency / Organization Name
Caseworker Name
Caseworker Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Caseworker Email
example@example.com
Medical conditions to be aware of in an emergency
Takes prescription medications?
*
No
Yes
Dietary restrictions or allergies?
*
No
Yes
Dietary restrictions / allergies description
Requires accessibility accommodations?
*
No
Yes
Accessibility accommodations description
Vehicles and Personal Transport
Do you own or operate a vehicle kept at or near the property?
*
No
Yes
Vehicle 1 - Make / Model / Year
Vehicle 1 - License Plate Number
Vehicle 1 - State of Registration
Vehicle 1 - Color
Vehicle 2 - Make / Model / Year
Vehicle 2 - License Plate Number
Vehicle 2 - State of Registration
Vehicle 2 - Color
Do you own a scooter, e-bike, or other motorized personal transport?
*
No
Yes
Scooter, e-bike, or other personal transport description
References
Reference 1 - Full Name
*
First Name
Middle Name
Last Name
Reference 1 - Relationship
*
Reference 1 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 1 - How long known
Reference 2 - Full Name
*
First Name
Middle Name
Last Name
Reference 2 - Relationship
*
Reference 2 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2 - How long known
Referral Source and Sign-Off
How did you hear about Plan a Purpose?
Caseworker / social worker referral
Friend or family
Online search
Social media
Community organization
Other
How did you hear - Other
Applicant Signature
*
Printed Name
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
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