1. Applicant Name:
2. Current Address:
3. City:
4. State:
6. Telephone:
5. Zip code:
7. Email address:
8. Other Contact information (e.g. friends, family, case manager) in case applicant cannot be reached at
the above: (include name, telephone number and if a detailed message can be left with these persons)
9. Household Composition:
Please identify all members of your household who will be living in the housing unit in the space provided below:
Last name, Middle Initial,
First name
Head of
Household Social Security #
Total number of household members expected to live in the unit?
10. Ethnicity
 Hispanic/Latino
 Non-Hispanic/Non-Latino
 Decline to answer
11. Race
American Indian or Alaskan Native
Black/African American
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Asian & White
Black/African American & White
American Indian/Alaskan Native & Black/African American
Other Multi-racial
Decline to answer
Date of Birth & Age
How many adults in the household have the following:
Head of Household
Other adults (age 18+)
Mental illness
Alcohol Abuse
Drug abuse
HIV/AIDS and related diseases
Developmental disability
Domestic violence
Other (please specify)
13. Do you or any member of your household have any significant health problems? Yes  No
If yes, please explain?
14. Where do you currently receive health care?
15. Current Living Situation
 Living in a place not designed for human habitation. Specify:
Current length of stay: _____ days
 Living in emergency shelter. Name of Shelter: _________________________________________
Current length of stay: _____ days
Transitional housing for homeless persons Program Name:
Current length of stay: ____ days
 Living in an institution/facility. Name of Facility:
Current length of stay: ____ days
 Other: Specify:
Current length of stay: _____ days
16. How did you become homeless?
17. How long have you been homeless?
18. Where was your last permanent address?
19. Are you receiving now, or willing to accept support services?  Yes  No
(Participation in support services is not a condition of this program)
Updated 1/26/2015
20. Current services and providers (include contact persons and telephone number):
21. Are you willing to allow a Housing Support staff person to conduct a monthly in-home visit for the
purpose of identifying any threats to your housing stability?
 Yes  No
(One monthly in-home visit is a condition of the Linkages Program)
22. How can Linkages help you maintain your housing?
 Help with money management or getting rep payee
 Help in keeping unit clean
 Regular contact with a case manager/worker
 Help in communicating with landlord /other tenants
 Help setting limits with friends
 Other:
 I don’t know
23. My housing preference is:
 A room with shared kitchen/bathroom facilities with another individual (e.g. roommate)
 An apartment with my own kitchen and bathroom facilities (not sharing with non-household
I understand that this application is not an offer of housing. I authorize (Housing Support agency) to
verify the truth of the information I have given in this application. I understand that the information
contained in my application may be subject to audit. I understand that my false statement or
misrepresentation may result in the cancellation of my application and program participation should I
begin to receive rental assistance.
I certify that the information that I have given in this application is true and correct.
Applicant Signature
Updated 1/26/2015