Connecting people and fostering independence through innovative and affordable housing, because everyone needs a place to call home.

HOME SEEKER APPLICATION

To complete the application process, copies of your photo ID, social security card, and proof of income are required. Please submit them along with your application. A background check is also required for which there is a $30.00 fee. Incomplete application packets are only kept for 30 days before they are destroyed.
Today's date*

MonthDayYear
Have you ever applied with Shared Housing Services before?*
If yes, when?

MonthDayYear
How did you hear about Shared Housing Services?
Personal Information
Gender*
Name*

First and Middle NameLast Name
Current/Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Maiden or other names used*
Cell Phone Number

Area CodePhone Number
Home Number

Area CodePhone Number
Best time to call
E-mail
Emergency Contact:*
Emergency Contact:
Relationship:*
Relationship:
Emergency contact phone number*

Area CodePhone Number
Are you a veteran*
Are you a veteran?
Last place of residence*
Last place of residence
Have you lived in any other state in the last 10 years?*
Have you lived in any other state in the last 10 years?
If yes, please list the state(s) and for how long:
Last four numbers of Social Security*
Last four numbers of your Social Security number?
ID/License #*
ID/License #
Age*
Age
Date of birth:*

MonthDayYear
Race
Ethnicity
Hispanic
Have you been through Coordinated Entry For Housing?
Marital Status:*
Marital Status
Are you homeless?*
Are you homeless?
Are you in a shelter?*
Are you in a shelter?
If yes, which shelter?
How long have you been homeless?
How many times have you been homeless?
Are you?*
Are you?
Have you experienced domestic violence?*
Have you experienced domestic violence?
If yes when?
What is your health condition compared to people your age?*
Any past drug use? *
Any past drug use?
Last used?
Have or are you receiving treatment?
Where?
Are you disabled?*
Are you disabled?
If yes, what type of disability do you have?*
Start date

MonthDayYear
Diagnosed Disability type
Are you receiving services for your disability?
If yes, what services?
Do you receive benefits for your disability?
If yes, what benefits are you receiving?
Start date

MonthDayYear
What medications are you currently taking?
Names in household:

Please list all members of household (other than yourself) that you are seeking housing for.
First household member:
Name

First NameLast Name
Relationship to applicant?
Gender
Age?
Date of birth

MonthDayYear
Race
Last four numbers of Social Security
Second household member:
Name

First NameLast Name
Relationship to applicant
Gender
Age?
Date of birth

MonthDayYear
Race
Last four numbers of Social Security
Third household member:
Name

First NameLast Name
Relationship to applicant?
Gender
Age?
Date of birth

MonthDayYear
Race
Last four numbers of Social Security
Of the children listed above, who is currently attending school?
Income:

Complete one for each source of income:
Source of income
Source of income
Source of income
Amount Received
Amount Received
Amount Received
Total monthly income*
Total monthly income
Monthly Living expenses:

Please list amount paid for each catagory
Food
Auto (insurance,payment,gas)
Child care
Internet-Streaming Subscriptions
Home/Cell phone
Healthcare Insurance
Storage
Credit cards
Other
Total monthly expenses*
Total monthly expenses
Budget comments:
Employment/Education
Are you currently employed?*
Are you currently employed?
Present or most recent employer?*
Present or most recent employer?
Length of employment?
Occupation?*
Occupation?
Are you a student?*
Are you a student?
Year in school?
Estimated graduation date?

MonthDayYear
Housing
Have you ever been evicted?*
Have you ever been evicted?
If yes, how many times?
Have you shared housing before (non-family)?
Was it successful?
Is this move urgent?
When?

MonthDayYear
Criminal History
Have you been involved with CPS?*
Have you ever been involved with CPS?
When

MonthDayYear
Have you ever been detained, arrested, or convicted of a crime?*
Have you ever been detained, arrested, or convicted of a crime?
When?

MonthDayYear
Do you have active warrants?*
Do you have active warrants?
If you answered yes to any of the above questions, please explain:
Is anyone forcing you to work in a profession against your will or taking money you rightfully earned?*
Shared Housing Information
Please check at least 3 goals you want to achieve to become more self sufficient and/or gain a better quality of life through homesharing.*

To obtain affordable housingBe within walking distance to work/school or bus lineTo improve quality of living situationMaintain stable housingAble to meet monthly housing costFacilities to maintain personal hygiene and laundryTo better meet nutritional needsSafe/Secure housingA place to study/do homework or further educationTo overcome homelessnessTo obtain independent housing and not rely on relatives/friendsTo help someoneTo increase incomeCompanionshipReceive servicesProvide services for free room and board and/or incomeOther
Please list the top 3 locations you desire to live:
1.*
2.
3.
Matching Criteria

Please answer all the questions below so that we can better match your needs.
Please respond to the following questions to describe yourself:
I identify my gender as:*
I identify me gender as:
If other please explain:
Are you a couple?*
Number of children*
Total number of people*
Do you drink?*
Do you drink?
Do you smoke?*
Do you smoke?
Do you have pets?*
Do you have pets?
Do you have furniture?*
Do you have furniture?
Do you have storage?*
Do you need storage?
Do you have any special requirements?
Please respond to the following questions to determine your preferences:

Are you okay living with...
With a male?*
With a male?
Comments
With a female?*
With a female?
Comments
With a couple?*
With a couple?
Comments
With children?*
With children?
Comments
How many people total are you willing to live with?
In a home with smoking?*
In a home with smoking?
Comments
In a home with drinking?*
In a home with drinking?
Comments
In a home with pets?*
In a home with pets?
Comments
In a furnished bedroom?*
In a furnished bedroom?
Comments
Do you need storage space?*
Do you need storage space?
Comments
Other:
What is your current rent?*
What is you current rent?
What is the maximum rent you can pay?*
What is the maximum rent you can pay?
Services
Are you interested in exchanging services for: reduced or free room and board?*
Are you willing to provide any of the following services?

HouseworkCookingErrandsHandy manDrivingGardeningLaundry
Caregiving?
Experience (years)
Other services you are willing to provide:
Compatibility:
What kind of person would you be compatible with?*
What irritates you about people?*
Do you have some traits that might irritate a home sharer?*
What would someone like about you?*
Needs:
Do you have any constraints in daily living?*
If yes, please describe:
How do you deal with them?
Can you manage stairs?*
Can you manage stairs?
How many rooms do you need?*
How many rooms do you need?
Which floor would you prefer to be on?*
Do you need to be near public transportation?*
Do you need to be neat public transportation?
Do you drive?*
Do you drive?
Do you own a car?*
Do you own a car?
Do you need parking space?*
Do you need parking space?
If you find a housemate through other efforts will you notify Shared Housing Services?*
Do you have any concerns and/or questions about homesharing?
Criminal History Policy
As a social service agency, we value safety and well-being of our clients, employees, and volunteers. It is therefore the policy of Shared Housing Services (SHS) to carefully screen all applicants for any criminal charges, arrests, convictions, and warrants. Applicants are screened through Sound Screening's multistate background check and the Washington State patrol.

Based on the information received by SHS through a completed background check, it is our policy not to refer any applicant to the Adult Home Share Program who has been charged, arrested, or convicted of the following crimes within the last ten years: felonies, thefts, domestic violence, crimes of child or elder abuse, and any actions involving destruction of property or physical violence toward persons. Additionally, any active warrants will also serve as grounds for denial of participation from the program, regardless of how old the warrant is. Applicants must resolve all active warrants and go through the appeal process in order to be reconsidered for participation. Clients who possess a criminal history that features sexual crimes, murder, or voluntary manslaughter within their lifetime will be automatically disqualified and unable to request an appeal.

Upon receipt of an adverse criminal history report, the applicant will be sent a letter denying their application due to relevant criminal history. It will state which crimes fall under the policy criteria as well as procedures to follow if the client wishes to seek review/reconsideration through the appeal process. The client is allowed a period of two months to schedule a criminal appeal appointment. If the client fails to do so within this given timeframe, they will not be able to reapply for entrance into the program for the next two years.

Policy on nondiscrimination: All services offered by SHS are provided in a manner which is free from discrimination on the basis of race, color, religion, sex, sexual orientation (gender identity/expression), national origin, age, handicap, and familial status.
Acknowledgment*

I certify that I have read the Criminal History Policy and that I understand and agree to the above information.
E-signature (participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/Partner))

First NameLast Name
Date

MonthDayYear
Shared Housing Services Release of Information (general)
I hereby authorize The Shared Housing Services (SHS) staff to send information to and discuss my personal circumstances with SHS coordinators and staff of other agencies.

It is understood that any interchange of information made between staff and coordinators of SHS and other agencies will be used only for purposes of attempting to determine appropriate services on my and my family's behalf.

I also authorize SHS staff to provide information supplied by myself and information on any arrest and/or criminal convictions obtained by SHS to potential home sharers in the process of attempting to bring about a home sharing arrangement on my behalf.
Acknowledgment *

I agree to the release of information as stated in the Shared Housing Services Release of Information form.
E-signature (Participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/partner)

First NameLast Name
Date

MonthDayYear
Agreement of Non-Liabilty
I understand that the staff of Shared Housing Services (SHS) will use their facilities to bring together those who have available housing (homeowner's) with those who express a desire for housing (home seeker's).

I, as a homeowner/home seeker, understand that SHS is not the agent of either party, but acts only as a facilitator, to provide the opportunity for the parties involved to come together and work out an acceptable housing agreement.

I, as a homeowner, am not relying entirely on SHS to screen home seekers. All credit checks, references and all other background information will be obtained and/or confirmed by myself.

I, as a home seeker, am not relying entirely on SHS as to the homeowner's background or as to condition of the premises and their suitability for my needs. I agree to obtain and/or confirm information myself.

Any disputes between the homeowner and home seeker which may arise shall not involve the staff of SHS, either individually or as a group, and I will not hold staff responsible for any claims, damages, or other consequences which may arise from any home sharing arrangement.

I have also been advised to seek the services of an attorney should I have any questions about my legal rights and the laws of the State of Washington.
Acknowledgment*

I have read and understand the Agreement of Non-Liability.
E-signature (Participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/Partner)

First NameLast Name
Date

MonthDayYear
Program Exit Guidelines
Shared Housing Services (SHS) is a non-discriminatory, equal opportunity non-profit, shared housing agency. We strive to serve Tacoma, larger Pierce County, and South King County, regardless of gender, age, race, religion, sexual preference (gender identity/expression), or socio-economic status. As part of the program, SHS requires everyone to provide copies of photo identification, Social Security card, and proof of income. In addition to this, all applicants for SHS are required to pay a $30 criminal background fee and pass a criminal background check based on the agency's criminal history policy. If a person is having trouble meeting any of these requirements, he or she should talk with staff to discuss alternatives.

Below is a list of reasons a participant may no longer receive services and be exited from the program:
1. Falsifying information
2. Disrespectful to staff in person, on the phone, or in writing
3. Disrespectful behavior toward another home sharer or home provider
4. Damage done to SHS property, the property of a home provider, or the property of a home seeker
5. Inappropriate behavior or boundaries toward staff or a program participant
6. Crimes or illegal actvity committed while in the program
7. Non-compliance with substance abuse or mental health treatment
8. Lack of contact by a non-matched program participiant by phone, email, and mail after 2 months
9. Failure to comply with services or rent contractually agreed upon by the home seeker and home provider
10. Failure to comply with Washington State landloard/tenant laws
11. If the home becomes uninhabitable or not fit for home sharing
Staff exercises their right to exit anyone from the program if they fall into one of the above listed categories. The list is not comprehensive and someone may be asked to leave for another reason. In addition, staff may use discretion at anytime and allow a participant to stay in the program based on the nature of the offense.
Acknowledgement*

I have read and understand the above Program Exit Guidelines. I acknowledge that anything listed above may result in dismissal from the program, and that I am responsible for my own behavior toward staff, volunteers, and program participants.
E-signature (Participant)*

First NameLast Name
Date*

MonthDayYear
Date

MonthDayYear
E-signature (Spouse/Partner)

First NameLast Name
Photo/Video/Audio Media Release
By acknowledging this release, I give Shared Housing Services (SHS) permission to use (1) my picture-including photos, videos, and electronic images, and (2) my voice-including sound and video recordings.

This gives Shared Housing Services' employees and partners permission to publish, reproduce, and distribute my name, image, and voice in all languages, media, formats, and markets now known or created in the future, including, but not limited to: Conferences and fundraising events, inclusion in newsletters, press releases, blogs, social media, donation requests, news coverage, advertising via television and internet, and website content.

I agree to hold harmless SHS and its staff and partners for any alteration of my image or voice, intentional or unintentional, which may arise in the production process.

I waive the right to receive payment for SHS use of any of the material described above, and to inspect or approve finished photos, audio, or video.
Minors:

I certify that I am the legal parent/guardian of the following minor(s), under the age of 18, to whom this Photo/Video/Audio Media Release shall apply
Name 1

First NameLast Name
Name 2

First NameLast Name
E-signature (Parent/Guardian)

First NameLast Name
Acknowledgement*

I am 18 years of age or older, have read the Photo/Video/Audio Media Release and understand its contents.Client(s) decline photo release*
Type a question
* Declining this release has no effect on distribution of services.
E-signature (Participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/Partner)

First NameLast Name
Date

MonthDayYear
Completed Application Packet
I understand that my application will not be complete until I come into Shared Housing Services (SHS) Monday-Friday 8:00am -4:00 pm to complete the background check and pay the $30.00 fee. I also understand that I must bring my photo ID, social security card, and proof of income to SHS for verification and photo copies. In addition, I am aware that all incomplete application's will be destroyed after 30 days.*

I have read and understand the steps required for my Home Seeker application to be completed.
E-signature (Participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/Partner)

First NameLast Name
Date

MonthDayYear
Type a question
Should be Empty:

HOME SEEKER APPLICATION

Personal Information

Names in household:

First household member:

Second household member:

Third household member:

Income:

Monthly Living expenses:

Employment/Education

Housing

Criminal History

Shared Housing Information

Matching Criteria

Services

Compatibility:

Needs:

Criminal History Policy

Shared Housing Services Release of Information (general)

Agreement of Non-Liabilty

Program Exit Guidelines

Photo/Video/Audio Media Release

Completed Application Packet