RESIDENT APPLICATION
Independent Living / Shared Housing Program
Please complete this application accurately. Submission does not guarantee acceptance or placement. Applications are reviewed based on program eligibility, available space, and the applicant's ability to live safely and independently in a shared housing environment.
1. APPLICANT INFORMATION
Full Legal Name *
*
First Name
Last Name
Date of Birth *
*
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Best Contact Phone Number *
*
Format: (000) 000-0000.
Email Address *
*
ejemplo@ejemplo.com
Age
Gender
Marital Status
Address
Dirección de la calle
Dirección de la calle Línea 2
Ciudad
Estado / Provincia
Código Postal / Zip
Preferred Contact Method
Do you understand that each approved bed is assigned to one individual resident?
Yes
No
Are you requesting housing for anyone other than yourself?
Yes
No
If yes, please explain:
2. CURRENT HOUSING SITUATION
What is your current living situation? Check all that apply.
Homeless
Emergency shelter
Jail/prison release
Hospital discharge
Current lease ending
Staying with family/friends
Transitional housing
Treatment center
At risk of homelessness
Other
When do you need housing?
Referral Agency / Referral Source
Briefly explain why you are seeking housing:
3. INCOME & PAYMENT
What is your current source of income? Check all that apply.
Employment
SSI
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Income Sources
SSDI
Social Security
VA Benefits
Retirement/Pension
Unemployment
Family Support
Agency Assistance
Other
Approximate Monthly Income *
*
Employer (if applicable)
Are you able to provide proof of income?
Yes
No
Preferred payment schedule:
Weekly
Bi-Weekly
Monthly
Who will be responsible for paying your housing/program fee?
Self-Pay
Agency Paying
Family/Representative Paying
Other
Agency / Organization Name
Agency Contact Person
First Name
Last Name
Agency Phone
Format: (000) 000-0000.
Agency Email
ejemplo@ejemplo.com
4. INDEPENDENT LIVING ELIGIBILITY
Are you able to live independently without daily hands-on assistance or 24-hour supervision?
Yes
No
Do you need assistance with cooking, cleaning, bathing, dressing, personal hygiene, or other daily activities?
Yes
No
If yes, please explain:
Would you need transportation assistance?
Yes
No
Do you have your own vehicle?
Yes
No
Do you have a valid driver's license, state-issued ID, or passport?
Yes
No
Are you able to manage your own medications independently?
Yes
No
Are you able and willing to follow house rules, quiet hours, cleaning expectations, and resident responsibilities?
Yes
No
5. ROOM PREFERENCE
Which housing option are you interested in?
Shared Room
Private Room
Either option is fine
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Do you understand that this is a shared-living program and common spaces may be shared with other residents?
Yes
No
Are you comfortable living respectfully around other residents in a shared household?
Yes
No
6. SAFETY & PLACEMENT SCREENING
These questions help determine whether the placement can be safely and appropriately supported in an independent/shared living environment.
Do you currently have any legal restrictions, probation/parole requirements, or court conditions that may affect housing placement?
Yes
No
If yes, please explain:
Are there any immediate safety concerns or circumstances the program should know about before reviewing your application?
Yes
No
If yes, please explain:
Is there anything in your recent history that may affect your ability to safely live in a shared household?
Yes
No
If yes, please explain:
7. EMERGENCY & REFERRAL CONTACT
Emergency Contact Name
First Name
Last Name
Relationship
Emergency Contact Phone
Format: (000) 000-0000.
Case Manager / Social Worker
First Name
Last Name
Case Manager Phone
Format: (000) 000-0000.
Case Manager Email
ejemplo@ejemplo.com
8. PROGRAM ACKNOWLEDGMENT
I understand and agree to the program expectations stated above.
9. APPLICANT CERTIFICATION & SIGNATURE
By signing below, I certify that the information provided in this application is accurate to the best of my knowledge. I understand that false or intentionally misleading information may affect eligibility. I understand that submitting this application does not guarantee approval, acceptance, or housing placement.
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Applicant Printed Name *
*
First Name
Last Name
Date *
*
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Applicant Signature *
*
FOR OFFICE USE ONLY
Application Received Date
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Reviewed By
First Name
Last Name
Income Verified: Yes / No
Funding Verified: Yes / No
Room Requested
Room Approved
Requested Move-In Date
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Approved Move-In Date
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Application Status:
Approved
Pending
Waitlisted
Denied
Follow-Up Needed
Internal Notes:
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