Momentum Dwellings Safe, Stable, & Affordable Application
This form helps us review applications for housing at Momentum Dwellings. Please answer honestly. All information is kept private. Momentum Dwellings reserves full discretion in all housing decisions. Decisions are made in accordance with Fair Housing laws.If you have any questions, please reach out to Info@momentumdwellings.org
Personal Information
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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Date of Birth
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-
Month
-
Day
Year
Date
Social Security Number
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Gender
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Male
Female
Other
Government ID
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Drivers License
State ID
Passport
Upload ID
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of
Current Living Situation
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Self
With Family
With Roommates
Homeless/Shelter
Jail/Prison
Other
Why are you seeking housing with Momentum Dwellings?
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Health & Mental Health
Are you able to live independently and handle daily tasks on your own?
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Yes
No
Do you need any accommodations to live safely and comfortably in shared housing?
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Yes
No
Please describe the accommodations you need
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Do you have any mental health diagnoses?
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Yes
No
What is the the diagnoses ? Please include all relevant details?
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Please describe your treatment plan
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Income & Financials
How much money do you make every month?
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Income Source (select all that apply)
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Job
SSI/ SSDI
Vouchers
Non profit Assistance
Other
Please Upload Proof of Income (Pay stubs, Bank Statements, Award Letter ETC.)
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Do you have the first month’s rent and move-in fee available today?
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Yes
No
When will you have it?
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Month
-
Day
Year
Date
Background
Have you been in jail or prison within the last 5 years?
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Yes
No
What Was the Crime?
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When were you released
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Month
-
Day
Year
Date
Are you currently on probation or parole?
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Yes
No
What is your TDCJ Number
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Are you a registered sex offender? All applicants will be subject a RSO search
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Yes
No
Emergency Contact
Name
*
Relationship
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Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
House Rules & Agreement
This is a community living situation in a home with multiple people. We don't have individual apartments. Are you okay living in a group situation?
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Yes
No
This is a program, not a lease. You could be removed immediately for breaking the rules of the house or causing disturbances. Please acknowledge that you understand this.
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Yes
No
All of our houses are sober environments. Alcohol, marijuana, and illegal substances are not allowed on the property, and anyone caught with them will be immediately removed. Please acknowledge that you understand this.
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Yes
No
Are you a minor or have minors with you? We currently only house adults
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Yes
No
Do you have a pet or a service? Note: We currently can not accommodate animals.
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Yes
No
Consent
I authorize Momentum Dwellings to: 1. Run background, criminal, eviction, and credit checks; 2. Verify income, housing history, rental assistance, and references; 3. Contact my payee, case manager, employer, or emergency contact if needed.
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Yes
No
I release Momentum Dwellings, its staff, my case manager, and listed references from any liability related to the sharing or verification of information for this application.
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Yes
No
I understand that providing false or incomplete information may result in denial or removal from housing.
Yes
No
Signature
Please Type Your Full Legal Name
Todays Date
-
Month
-
Day
Year
Date
Submit
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