Rental Subsidy Referral Application

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First Avenues Rental Subsidy Application

Date: ___________________________

Family Name: ______________________________________________________________________________

Phone #:__________________________ Secondary Phone #:__________________________

Monthly Income:_________________________ Income Source(s):_________________________________

Referring Agency: ___________________________________________________________________________

Contact Person:_____________________________________________________________________________

Phone Number:_____________________________________________________________________________

Please note that once this Referral Application is competed and submitted, you will be contacted for an appointment. Please bring the following documents to your intake appointment. Thank you for your referral.

 Recent Income Verification

Valid IDs

 Birth Certificates for Children

 Social Security Cards

Resume

Documentation of Training Program (if applicable)

Credit and Eviction Report

Certificate of Homelessness or Letter of Residency (if applicable)

Please fax, mail or email referral application to:

Hamilton Family Center

First Avenues: Housing Solutions for Families

Attention: Homeless Prevention Case Manager

(415) 614-9062 (fax)

Please contact a Homeless Prevention Case Manager to answer any questions:

(415) 614-9060 ext. 101, ext. 102, ext. 109, ext. 107 or ext. 108

1

255 Hyde, San Francisco, CA 94102

415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Adults Living in Household:

Name

(List Head of Household First)

Social Security Age DOB Relationship

(to Head of Household)

Children and/or Dependents Living in Household (Must have custody of minors under 18):

Name Sex Relationship

(to head of household)

Age DOB In School/

Childcare?

Name of School/

Childcare

List any children not in custody:

Name Relationship DOB Where do they live?

Current Address or shelter name:________________________________________________________________

If homeless, briefly explain the circumstances that brought the family to homelessness?______________________

__________________________________________________________________________________________

__________________________________________________________________________________________

How long has the family been homeless?_________________ Is this the first time they are homeless? Yes No

What is the date the family became homeless?_____________________________________________________

Other homeless shelters/programs/services used by the family:

(please include all rental assistance/subsidy programs that you have ever used)

Agency/Shelter/Program Name Dates

2

255 Hyde, San Francisco, CA 94102

415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Rental History:

List Housing History for the past 3 years:

Address Rent Amount Paid Per Month Dates

Does the family have any evictions? Yes No If yes, please explain (dates, circumstances, etc).___________

__________________________________________________________________________________________

Has the family had a lease in their names? Yes No If yes, when and for how long?__________________

Does the family have significant credit barriers to obtaining housing? Yes No If yes, what? Any housing related debts (utilities, evictions, etc.)___________________________________________________________

Is the family working to pay off or consolidate debts? Are they working with a credit counselor?_______________

__________________________________________________________________________________________

Employment History:

List your most recent employment position & company: _____________________________________________

How long were you at that company? __________________________

Reason for leaving? __________________________________________________________________________

Month/Year that you left that company: __________________

What is the longest length of time that you have stayed at one company? ________________________________

Position title/company: ______________________________________________________

Reason for leaving ____________________________________________________

Month/Year that you left that company: __________________

3

255 Hyde, San Francisco, CA 94102

415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Do you have professional references available? Yes No

Education History

What was your highest grade completed? ________________________________________

Please list all certificate, training programs or classes you have completed

1. _______________________________________________________ Date: __________________

2. _______________________________________________________ Date: __________________

3. _______________________________________________________

Current Family Income:

Date: __________________

Do you currently receive Food Stamps? ________ If yes, please list amount $: ____________

Income Source Amount

SSI

SSDI

CalWORKs

Employment/Unemployment

Child Support

GA

Other (please list source):

Total Monthly Cash Income (please list gross, take-home income, include undocumented income)

50% of Total Monthly Cash Income

If all or part of income is CALWORKS, please complete the following:

CALWORKS Status: Welfare to Work Exempt Sanctioned

If exempt or sanctioned, please explain (when and for how long) ______________________________________

4

255 Hyde, San Francisco, CA 94102

415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Chemical Dependency/Alcoholism History

1.) Is anyone in the family actively using? Yes No

2.) If anyone is in treatment/recovery, where and for how long? (Please be very specific about length of recovery time)______________________________________________________________________________________

__________________________________________________________________________________________

History of Domestic Violence

1.) Does the family have a history of domestic violence? Yes No

If yes, Indicate length of time away from abuser. __________________________________________________

2.) Any restraining orders? Yes No

3.) Any formal support, i.e. DV shelter, support groups?_____________________________________________

Criminal History:

Do any adults in the household have a felony? Yes No If yes, for what and when? ____________________

__________________________________________________________________________________________

5

255 Hyde, San Francisco, CA 94102

415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Please list at least 3 steps to increase your family income within 3-24 months. Provide details when necessary.

Plan A: _________________________________________________________________

Action required: __________________________________________________________

Expected time to reach goal: _______________________________________________

Additional information: ______________________________________________________________________

__________________________________________________________________________________________

Plan B: _________________________________________________________________

Action required: __________________________________________________________

Expected time to reach goal: _______________________________________________

Additional information: ______________________________________________________________________

__________________________________________________________________________________________

Plan C: _________________________________________________________________

Action required: __________________________________________________________

Expected time to reach goal: _______________________________________________

Additional information: ______________________________________________________________________

__________________________________________________________________________________________

I hereby verify that all the information provided is true and accurate to the best of my knowledge.

_____________________________________

Signature

_____________________________________

__________________

Date

__________________

Signature Date

6

255 Hyde, San Francisco, CA 94102

415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

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