Housing Questionnaire Housing Questionnaire Full Name * Date of Birth * Phone * Email * Current Address Preferred Contact Method * Phone Email Text Message Mail Number of Adults in Household Number of Children in Household List Hold Members Name, Relationship & Age * Current Living Situation * Renting Own Home Staying with Family/Friends Shelter Transitional Housing Unsheltered / Homeless OtherOther How Long Have you been in your current living situation?How Long Have you been in your current living situation? Reason for Seeking Housing Assistance * Eviction Notice Homelessness Domestic Violence Unsafe Living Conditions Overcrowding Financial Hardship Relocation Other (Please Explain)Other (Please Explain) Employment Status * Full-Time Part-Time Unemployed Retired Disabled Student OtherOther Monthly Household Income $Monthly Household Income $ Income Sources (check all that apply) Employment SSI/SSDI Social Security Unemployment Benefits Child Support Pension/Retirement Public Assistance OtherOther Housing Preferences i.e. Preferred Housing Type: * Apartment House Shared Housing Senior Housing Accessible Housing Other Number of Bedrooms NeededNumber of Bedrooms Needed Maximum Affordable Monthly Rent $Maximum Affordable Monthly Rent $ Preferred Location/AreaPreferred Location/Area Special Needs/Accommodations Yes No If Yes, please describeIf Yes, please describe Emergency Contact Information (Name, Relationship and Phone Number) * Additional Information Applicant Certification Name * I hereby certify that the information provided on this form is true and complete to the best of my knowledge. Date Submit If you are human, leave this field blank.
