Senior Shared Housing Pre-Screening Form
Answer a few questions to help us review eligibility for affordable shared living.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which of the following best describes you?
*
Senior (age 55+)
Veteran
Individual with felony history
On a fixed income
Other
What is your primary source of income?
*
Please Select
Social Security
Disability Benefits
Veterans Benefits
Employment
Family Support
Other
Are you currently housed?
*
Yes
No
When are you looking to move?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please share any preferences or needs regarding shared living (optional)
Submit Application
Should be Empty: