Community & Management Offering Housing
This form focuses exclusively on capturing essential contact details, home layout/capacity, and background check authorization so the case manager can verify your profile for a potential victim placement or emergency housing match.
1. Host Contact Information
Primary Host Full Legal Namee
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Property Physical Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred By:
2. Accommodation & Matching Details
Target Populations Served (Check All That Apply)
*
Survivors of Violence: Women and children fleeing domestic violence, dating violence, sexual assault, or stalking
Homeless Veterans: Individual military veterans or veteran families in need of transitional or permanent housing
Unsheltered Individuals & Families: Individuals or families currently experiencing homelessness
At-Risk Youth & Young Adults: Young adults (ages 18–24) aging out of foster care or experiencing housing instability
Persons in Recovery: Individuals participating in accredited substance use recovery programs or sober living transitions
Re-Entry & Justice-Involved Individuals: Persons successfully re-entering the workforce and community following justice system involvement
Seniors & Older Adults: Independent elderly individuals seeking affordable, stable housing
Persons with Disabilities: Individuals requiring accessible or supportive independent living arrangements
Other CoC / HUD Priority Populations: Any individual or family referred directly by a local Continuum of Care (CoC) or municipal housing authority
Type of Space Offered:
*
Private Bedroom (Shared Living Space/Kitchen)
Private Bedroom with Private Bathroom
Separate In-Law Suite
Guest Apartment
Single Family Home
Townhouse / Duplex
Condominium
Apartment
Requested Monthly Compensation / Room/House Rate
*
Current Capacity Offered
*
1-2 Adults
3-4 Adults
1 -2 Children
3 - 4 Children
Can you accept immediate/emergency same-day placements?
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Yes
No
Household Members (Required for Background Check - Full Name and DOB)
*
Full Name and DOB
Access to bus stop or railway?
*
Yes
No
Distance to the nearest bus stop or railway (miles):
*
4. Consent for Case Manager Referral & Background Check Authorization
Signature: By signing below, I acknowledge and authorize the following: Case Manager Matching: I consent to J. F. Jeter Realty, Inc. sharing my host profile and contact information directly with partner Case Managers and Victim Service Providers to evaluate emergency and long-term housing placements. Background Screening: I authorize Case Manager and its screening partners to perform criminal background and sex offender registry checks on all adult household members listed above. VAWA Address Confidentiality: I understand that all victim details and housing placements are strictly confidential under the Violence Against Women Act (VAWA) and agree never to disclose the identity or presence of placed individuals.
*
Your information is collected solely to process background screenings and coordinate matches with credentialed case managers. All data remains 100% confidential and secure in accordance with our Privacy Policy.
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