• Housing Services Application

  • Date application is being completed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Applicant's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Are you a veteran?
  • Gender
  • Marital Status
  • Race/Ethnicity
  • Education Level
  • Do you have a disability in any of the below areas? Please check all that apply.

  • Housing History

  • Is the applicant currently homeless?
  • What has been your living situation in the last week?

  • Rental Information

  • Do you currently live in rental housing?
  • Format: (000) 000-0000.
  • Are you currently behind in paying your rent?
  • Are utilities included in the rent?
  • Have you ever been evicted?
  • Is there an eviction pending?
  • If there is a pending eviction--what date?
     - -
    2 digit month, 2 digit day, 4 digit year

  • Household Composition

  • If you are single, are you willing to share a home (have a housemate)?
  • Some housing programs require at minimum (one contact per month) case management services. Are you willing to accept these services for the duration of program participation?
  • What sources of income? Please check all that apply.
  • Have you ever been convicted of a felony?

  • Household Members

    Please list all other household members below
  • Date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Additional Household Member?
  • Date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Additional Household Member?
  • Date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Additional Household Member?
  • Date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender

  • References

    Please list two people that may be contacted as references for the housing program.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Acknowledgement

    Applications will be held for one year. Re-application will be necessary after that period.

  • Please read the statements below and then sign/date.

    I certify that the information given by me is true and accurate to the best of my knowledge.

    I understand that there will be information exchanged between Ravenwood Health and the apartment management or landlord regarding my housing needs.  This is being done with my approval.

    I understand that the references listed by me may be contacted by Ravenwood Health.

    I am willing to apply for entitements for which I may qualify (Section 8, SSI, SSDI, Block Grant Funds, PRC Funds, and/or other emergency funds).  

    I understand that as a housing applicant, the information I have provided on this application will be entered into HMIS (Homeless Management Information System) for the purpose of recording my housing needs adn placement, or non-placement into Ravenwood Health's Housing Services Programs. 

    By signing below I acknowledge that i have read and agree to all the above. 

  • Signature Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: