Roommate Application Form

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One-third of Las Vegas senior adults are facing housing instability today and that number is expected to double in ten years. With your support, Elder HelpLv will be able to profoundly impact this crisis and give seniors in Las Vegas resource information to secure home environments and the affordable housing they need and deserve.
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Name:
First Name
Last Name
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Birth Date
Month
Day
Year
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Phone Number:
Area Code
Phone Number
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Are you currently receiving Social Security, SSI, or Medicaid or have a case pending with Medicare, Medicaid SSI or VA
Social Security
Medicaid
Social Security Disability
VA
pending
Company Retirement Plan
None of the above
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What is your monthly Income ?
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E-mail Address:
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How were you referred to us?
Hospital
Social Services
Friend
Facebook
Twitter
Spotlight Senior Service
Other (please specify)
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Others:referred to us by
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Describe your situation and why are you in-need of Housing
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Are You
Female
Male
55 or Over
Veteran
Spouse of a Veterans
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Type of Bedroom Requested ?
Private Room
Shared Room
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Housing Providers are homeowners or renters (typically older adults) who want to share their homes, and have at least one available bedroom. Housing Providers join the program to share their homes with compatible, pre-screened Housing Seekers who can pay a monthly rent for the available room, offer assistance with household chores, or both. Housing Providers must be mentally, emotionally, physically and financially self-sufficient.

Housing Seekers are adults of all ages who may not wish to live alone or cannot afford to do so. They may be retired, employed, or students. They must be mentally, emotionally, physically and financially self-sufficient. Currently, the average age of our Housing Seekers is 65.

Elder HelpLv acts as an intermediary to screen both providers and seekers, match compatible roommates, roommates execute a roommate agreement and monitor ongoing matches
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