Associated Ministries Universal Program Application
Adult Home Share Program - AHS Home Provider
Eligibility Requirements:
Applicants must have an income and pass a background check to participate in the Adult Home Share Program.
AHS Home Provider Application Process
Thank you for your interest in applying to the Adult Home Share program. This program is for individuals seeking housing in a shared housing setting. Once the application is received, our staff will run a background check, conduct an in-person intake, then attempt to match you with one of our Home Providers. If we find there is a potential match, a "Match Meet" will be arranged for both you and the Home Seeker to meet one another to decide whether you want to live together. Either party may decide not to move forward. To complete the application process, copies of your photo ID and proof of income are required. You will be required to provide these at the time of your intake once your application has been processed. Incomplete application packets are only kept for 30 days before they are destroyed.
Important Note
Please be aware it is very difficult to find housing matches for home providers requesting more than $900 monthly rent.
Household Overview of Home Provider
Household Size
*
Number Adults
*
Number Children
*
Total Household Income (Monthly)
*
Income of all household members age 18+
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Applicant Basic Information:
Complete the Basic Information section accurately and thoroughly to the best of your ability.
First Name
*
Middle Initial(s)
Last Name
*
DOB
*
-
Month
-
Day
Year
Age
*
Gender
*
Please Select
Female
Male
Gender Fluid
Non-Binary
Transgender-Female
Transgender-Male
Decline to answer
Unknown
Other
Other Gender
Primary Race
*
Please Select
American Indian/Alaska Native/Indigenous
Asian/Asian American
Black/African American/African
Hispanic/Latina/e/o
Middle Eastern/North African
Native Hawaiian/Other Pacific Islander
White
Decline to answer
Unknown
Multi-Racial
*
Please Select
Yes
No
Secondary Race
*
Please Select
American Indian/Alaska Native/Indigenous
Asian/Asian American
Black/African American/African
Hispanic/Latina/e/o
Middle Eastern/North African
Native Hawaiian/Other Pacific Islander
White
Decline to answer
Unknown
Disability
*
Please Select
Disabled
Not Disabled
Decline to answer
Unknown
Health Insurance
*
Please Select
0-No Health Insurance
Employer Provided Insurance
Indian Health Services Program
Insured-Unknown Type
MEDICAID (State Health Insurance for Adults & Children)
MEDICARE
Private Pay/Direct Purchase Insurance
VA Medical Services
Decline to answer
Unknown
Primary Language
*
Please Select
English
Spanish
Arabic
Bengali
Cambodian
Chinese
French
German
Hindi
Italian
Japanese
Korean
Lahnda
Malay
Marathi
Persian
Polish
Portugese
Russian
Tamil
Telugu
Turkish
Twhulshootseed
Urdu
Vietnamese
Decline to answer
Other
Other Language
Marital Status
*
Please Select
Civil Partnership
Divorced
Married
Never Married
Separated
Widowed
Decline to answer
Unknown
Employment
*
Please Select
Employed
Employed-Full Time
Employed-Part Time
Employed-Temporary/Seasonal
Job Training Program
N/A
Not in Labor Workforce-Retired/Disabled/Minor Child
Self-Employed
Unemployed
Decline to answer
Unknown
Veteran Status
*
Please Select
Veteran
Not Veteran
Decline to answer
Education Level
*
Please Select
Graduate Degree
Associate's Degree
Bachelor's Degree
Vocational Certification
Some College
Some College (Current Student)
GED
Grade 12 - High School Diploma
Grades 9 - 11
Grades 7 - 8
Grades 5 - 6
Less than grade 5
School Program does not have grade levels
Decline to answer
Unknown
Select last grade completed
Pronouns
*
Please Select
She/Her
He/Him
They/Them
Decline to answer
Unknown
Other
Other Pronouns
Sexual Orientation
*
Please Select
Straight
Bi-sexual
Gay
Lesbian
Queer
Questioning/Unsure
Decline to answer
Other
Other Sexual Orientation
Are you currently fleeing domestic violence
Please Select
Yes
No
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Contact Information:
Complete the Contact Information section accurately and thoroughly to the best of your ability. If you have scheduling or phone/computer access challenges that make it difficult for you to be contacted, we encourage you to provide as much contact information as possible in the fields below so we have the best chance to reach you.
Phone Type
*
Please Select
Home
Message
Mobile
Work
NO PHONE
If no phone, select NO PHONE
Phone Number
If no phone, leave blank
Format: (000) 000-0000.
Alternate/Message Phone Type
Please Select
Home
Message
Mobile
Work
NO ALT PHONE
If none, select NO ALT PHONE
Alternate Phone Number
If no alternate phone number, leave blank
Format: (000) 000-0000.
Email
Preferred Contact Method
*
Please Select
Phone Call
Text
Email
Best Time to Contact
Please Select
Morning (9:00am-12:00pm)
Afternoon (12:00pm-5:00pm)
Other (enter specific time between 9:00am & 5:00pm)
Note: Staff are available for contact during regular office hours (9:00-5:00 Mon-Fri) Unless otherwise noted
Other Contact Time
Enter a specific time frame between 9:00am & 5:00pm
Additional Contact Details/Notes
If none, leave blank
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Housing Information
This section applies to your current living situation. Complete accurately and thoroughly to the best of your ability. If unsure of length of time at current location, use your best memory to complete the "How Long" and "Start Date" fields.
Housing Status
*
Please Select
Homeowner
Renting Apartment/House
Other
Other Housing Status
Rent/Mortgage Amount
*
If none enter $0
Housing Stability
Please Select
Stably Housed
Unstably Housed
Housing/Shelter Type
Please Select
Adult Family Home
Apartment
Assisted Living Facility
Correction Facility
House
Medical Facility
Mobile Home
Outside/Unsheltered
Residential Treatment Facility
RV
Shared Housing
Temporary/Transitional Housing
Vehicle
How Long
*
If unknown, please estimate
Start Date
/
Month
/
Day
Year
Date: If unknown, please estimate
Address:
Physical Address: Please enter the address where you currently reside.
Physical Address
*
House Number & Street
Apartment/Unit/Space #
Apt/Unit #
City
*
State
*
Please Select
WA
Other State
Other State
Zip Code
*
Add a separate Mailing Address?
*
Please Select
Yes
No
Mailing Address
*
Mailing Apartment/Unit/Space #
Mailing City
Mailing State
Please Select
WA
Other State
Other State
Mailing Zip Code
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Emergency Contact
An Emergency Contact is someone who is able to get ahold of you if we are unable to reach you regarding your application or important program information. If you have someone you want us to contact if we can't reach you, add them below.
Add Emergency Contact?
*
Please Select
Yes
No
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Relationship
Please Select
Advocate
Caregiver
Case Manager/Case Worker
Child
Counselor
Friend
Grandparent
Guardian
Parent
Spouse/Significant Other
Other Related Adult
Other Non Related Adult
Other (see case notes)
Consents:
Please Select
All/No Limitations
Appointment Information
Service Statuses (Check Available, Referral Received, Housing Opening, Etc.)
Other (see case notes) PM. Mm. M. . MMB? . . .. . .
Emergency Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Email
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Income Information
Provide the monthly amounts from all income sources received by the applicant. Complete this section thoroughly and accurately to the best of your ability.
Income Source 1
Please Select
NO INCOME
Wages
Bonuses
Commissions
Tips
Military Pay
DSHS Public Assistance-TANF
DSHS Public Assistance-ABD
SNAP Food Benefits
Social Security-SSI
Social Security-SSDI
Child Support
Alimony
Rental Income
Investment Income
Retirement Benefits
VA Benefits
Tribal Benefits
Student Financial Aid
Unemployment
Monthly Amount of Income Source 1
Add a second income source?
Please Select
Yes
No
Income Source 2
Please Select
Wages
Bonuses
Commissions
Tips
Military Pay
DSHS Public Assistance-TANF
DSHS Public Assistance-ABD
SNAP Food Benefits
Social Security-SSI
Social Security-SSDI
Child Support
Alimony
Rental Income
Investment Income
Retirement Benefits
VA Benefits
Tribal Benefits
Student Financial Aid
Unemployment
Monthly Amount of Income Source 2
Add a third income source?
Please Select
Yes
No
Income Source 3
Please Select
Wages
Bonuses
Commissions
Tips
Military Pay
DSHS Public Assistance-TANF
DSHS Public Assistance-ABD
SNAP Food Benefits
Social Security-SSI
Social Security-SSDI
Child Support
Alimony
Rental Income
Investment Income
Retirement Benefits
VA Benefits
Tribal Benefits
Student Financial Aid
Unemployment
Monthly Amount of Income Source 3
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Referred By:
Tell us how you heard about Associated Ministries Adult Home Share Program
How did you hear about us?
*
Please Select
Associated Ministries-Case Manager
Associated Ministries-Website
Project Homeless Connect
Outreach Events/Presentations
Case Manager/Social Worker/Counselor/Advisor
Family/Friend
School
Internet/Online Search
Social Media
Word of Mouth
Unknown/Don't Remember
Other
If Other, enter how you heard about us in "Other Referral Source" below
Enter the name of the agency, facility, or school where the person who referred you works.
Enter the name and/or location of the event or presentation where you heard about the program.
Other referral source
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Program Supplement to Application
Adult Home Share - AHS Home Provider Supplement
Property Information
This section applies to the property and location of the room you wish to share. Complete the Property Information section thoroughly and accurately to the best of your ability.
Do you live on the property?
*
Please Select
Yes
No
Property Address
*
Property Apartment/Unit/Space #
Apt/Unit #
Property City
*
Property State
*
Property Zip Code
*
Relationship to Property
*
Please Select
Owner
Renter
Other
Owner/Landlord Name
Owner/Landlord Contact Phone or Email
Property Type:
*
Please Select
House
Apartment
Mobile Home
Other
Other Property Type
Enter Other Type of Property
Number of rooms available to rent
*
Is the available room furnished?
*
Please Select
Yes
No
Is storage space available for tenants?
*
Please Select
Yes
No
Is the property located near bus lines?
*
Please Select
Yes
No
Property Monthly Mortgage/Rent Amount
*
Desired Monthly Rent Amount
*
Please note, the purpose of this program is to promote affordable housing options. Charging over $900 per month will limit the number of renter matches available to you.
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Program Supplement to Application
Adult Home Share - AHS Home Provider Supplement
Matching Criteria
Complete the Matching Criteria section accurately and thoroughly to the best of your ability, so we can best match your needs.
Your Smoking Habits
*
Please Select
Never
Sometimes
Regularly
Is Smoking Allowed?
*
Please Select
Yes
No
Negotiable
Alcohol Use
*
Please Select
Never
Sometimes
Regularly
Is Drinking Allowed?
*
Please Select
Yes
No
Negotiable
Do you or other tenants have pets?
*
Please Select
Yes
No
List Pets (number & type of pet)
Are pets allowed?
Please Select
Yes
No
List Allowable Pets
Do you have any allergies that might be impacted by a new tenant moving into your home?
*
Please Select
Yes
No
Housing related allergies
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Acknowledgements & Disclosures
Adult Home Share - AHS Home Provider
Please read each of the following program disclosures carefully.
Agreement of Non-Liability Disclosure
I understand that the staff of Associated Ministries 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 home seeker, understand that Associated Ministries 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 home seeker, am not relying entirely on Associated Ministries 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 Associated Ministries, 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.
I have read and understand Associated Ministries' Agreement of Non-Liability Disclosure
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Additional Documents and Application Packet Completeness
Additional information regarding identification and income is required to determine eligibility. The opportunity to uploaded ID and income documentation is provided through this application process. Associated Ministries will use the contact information provided to schedule an intake interview within 5 business days of submission of this application. Application will not be processed until all documentation is received. I understand that my application will not be complete until I submit necessary identification and income verification online or in person to Associated Ministries staff.
I have read and understand Associated Ministries' Additional Documents and Application Completeness Disclosure.
*
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Program Exit Guidelines
Program Exit Guidelines Associated Ministries 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, Associated Ministries requires everyone to provide copies of photo identification, Social Security card, and proof of income. In addition to this, all applicants must 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: This list is not comprehensive and someone may be asked to leave for a number of other reasons another reason in addition to the reasons listed here. In addition, staff may use discretion at anytime and allow a participant to stay in the program based on the nature of the offense.
I have read and understand Associated Ministries' Program Exit Guidelines Disclosure.
*
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Associated Ministries General Release of information
Associated Ministries Release of Information (general) Associated Ministries Release of Information (general) I hereby authorize Associated Ministries staff to send information to and discuss my personal circumstances with coordinators and staff of other agencies. It is understood that any interchange of information made between staff and coordinators of Associated Ministries 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 Associated Ministries staff to provide information supplied by myself and information on any arrest and/or criminal convictions obtained by Associated Ministries to potential home sharers in the process of attempting to bring about a home sharing arrangement on my behalf.
I have read and understand Associated Ministries' General Releases of Information Disclosure.
*
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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 Associated Ministries to carefully screen all applicants for any criminal charges, arrests, convictions, and warrants. Applicants are screened through the Washington State Patrol. Based on the information received by Associated Ministries 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 Associated Ministries 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.
I have read and understand Associated Ministries' Criminal History Policy Disclosure.
*
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Non Discrimination
All services offered by Associated Ministries are provided in a manner which is free from discrimination on the basis of race, religion, gender (gender identity/expression), sexual orientation, national origin, class, disability, or age.
I have read and understand Associated Ministries' Non Discrimination Disclosure.
*
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Upload Documents:
Please upload identification and income verification documentation.
Identification:
Browse Files
Drag and drop files here
Choose a file
Copy of Photo Identification (must be legible)
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Proof of Income:
Browse Files
Drag and drop files here
Choose a file
Paystub, SSI/SSDI or DSHS Award Letter,
Cancel
of
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Application Acknowledgement:
I certify the information I have provided in this application is true and accurate to the best of my knowledge. Sign and date below:
Signature
*
Date
/
Month
/
Day
Year
Submit
Should be Empty: