WEST DES MOINES HUMAN SERVICES HOUSING SOLUTIONS PROGRAM
APPLICATION
Date _____/_____/_____
Please PRINT Clearly. Information you provide will be verified.
HEAD(S) OF HOUSEHOLD NAME(S):____________________________________//____________________________________
(legal name)
(first)
(middle)
(last)
(first)
(middle)
(last)
ADDRESS (receive mail) _______________________________CITY________________________ZIP CODE_________________
PHONE (messages) _____________________________
__________________________
LAST PERMANENT HOUSEHOLD
ADDRESS:___________________________City_____________________State_____Zip____
OTHER NAME(S) YOU DO OR HAVE GONE BY:_____________________ _____________________
MARITAL STATUS: ___Single ___ Married ___ Divorced ___ Separated ____Other, explain___________________
WHAT IS YOUR CURRENT LIVING SITUATION? (circle) SHELTER - FAMILY MEMBER - RENTING – CAR –
FAMILY VIOLENCE – FACING EVICTION – OTHER______________________
HOUSEHOLD MEMBERS: Please list ALL people that will reside with you, including you.
NAME (complete)
M/F
BIRTHDATE
SS#
RELATION
1)________________________________________________________________________________________________________
2)________________________________________________________________________________________________________
3)________________________________________________________________________________________________________
4)________________________________________________________________________________________________________
5)________________________________________________________________________________________________________
6)________________________________________________________________________________________________________
7)________________________________________________________________________________________________________
8)________________________________________________________________________________________________________
9)_________________________________________________________________________________________________________________________
DO YOU HAVE OTHER CHILDREN NOT LIVING WITH YOU AT THIS TIME? YES____ NO____
Name
Age
Where do they live?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________________________________________________________________________________
Ethnicity (select only one, please circle) 1. Hispanic or Latino
2. Not Hispanic or Latino
Race (select one or more) 1. American Indian or Alaskan Native 2. Asian 3. Black or African American
4. Native Hawaiian or Pacific Islander 5. White
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EMPLOYMENT INFORMATION:
List ALL employment, list current employment first. Complete all spaces provided. The information should be completed for ALL adults providing
financial support to the family.
APPLICANT’S NAME _________________________________ APPLICANT’S NAME ____________________________________________
CURRENT EMPLOYER________________________________ CURRENT EMPLOYER___________________________________________
ADDRESS___________________________________________ ADDRESS______________________________________________________
CONTACT PERSON__________________________________ CONTACT PERSON_____________________________________________
PHONE ______________________ HIRE DATE________
PHONE______________________HIRE DATE ____________________
JOB TITLE/DUTIES ____________________________________
JOB TITLE/DUTIES______________________________________________
______________________________________________________ ________________________________________________________________
GROSS MONTHLY
$____________________________ GROSS MONTHLY
$_____________________________________
GROSS ANNUAL INCOME $____________________________ GROSS ANNUAL INCOME $_____________________________________
PAST EMPLOYMENT HISTORY:
List ALL employment during the last five years. The information should be completed for ALL adults providing financial support to the family.
______________________________________ ___________________
__________________________________________________________
__________________________________________________________
___________________________________________________________
__________________________________________________________
___________________________________________________________
__________________________________________________________
___________________________________________________________
What employment goals do you have for the next 2 years? ________________________________________________________________________
EDUCATIONAL BACKGROUND: Please complete the following for all adults in household. If you need more space use a separate piece of paper.
NAME:__________________________________________________ NAME:_______________________________________________________
GRADE COMPLETED (circle) 1
2 3 4 5 6 7 8 9 10 11 12 +_____
High School Diploma?_______ - GED?_________
///
1 2 3 4 5 6 7 8 9 10 11 12 +_____
High School Diploma?______ - GED?______
ADDITIONAL TRAINING:
ADDITIONAL TRAINING:
DEGREE__________________________________________________ DEGREE_______________________________________________________
VOCATIONAL/TRADE SCHOOL_____________________________
VOCATIONAL/TRADE SCHOOL___________________________________
DEGREE/CERTIFICATE______________________DATE_________
DEGREE/CERTIFICATE_______________________DATE_____________
Do any adults have future educational plans or goals? ____no ____yes, please explain __________________________________________________
________________________________________________________________________________________________________________________
Please list schools/educational institutions that the children in the household attend.
NAME _____________________________________SCHOOL _____________________________________ GRADE__________________
NAME _____________________________________SCHOOL______________________________________ GRADE__________________
NAME ____________________________________ SCHOOL______________________________________ GRADE__________________
NAME _____________________________________ SCHOOL______________________________________GRADE___________________
NAME_____________________________________ SCHOOL______________________________________GRADE___________________
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LIST CURRENT AGENCIES YOU ARE WORKING WITH (including DHS information)
AGENCY
CONTACT PERSON
LOCATION
PHONE #
1.
_______________________________________________________________________________________________________________
2.
_______________________________________________________________________________________________________________
3.
_______________________________________________________________________________________________________________
4.
_______________________________________________________________________________________________________________
5.
_______________________________________________________________________________________________________________
FINANCIAL INFORMATION:
INCOME: Please list all sources of income.
Employment hours and wages/week ___________________________________________
Monthly Gross $ _____________________________
Employment hours and wages/week ___________________________________________
Monthly Gross $ _____________________________
Child Support ____________________________________________________________
Monthly Amount _____________________________
Social Security ____________________________________________________________
Monthly Amount _____________________________
Unemployment ___________________________________________________________
Monthly Amount _____________________________
FIP, how long received?_____________________________________________________
Monthly Amount _____________________________
Other: ___________________________________________________________________
Monthly Amount _____________________________
GROSS MONTHLY INCOME:
$_____________________________
Does the family maintain a checking, saving, or share draft account? ____no ____yes, if yes please complete the following.
NAME ON ACCOUNT
TYPE OF ACCOUNT
NAME OF FINANCIAL INSTITUTION
BALANCE
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
DO YOU HAVE PAST DUE/OUTSTANDING BILLS OR UTILITIES? If so, describe:
_______________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Have any members of your family filed bankruptcy? ____no ____yes, please explain ________________________________________________
________________________________________________________________________________________________________________________
Does any member of the family have any judgments against him/her? This includes child support, alimony, court, taxes, legal or medical bills.
____no ____yes, please explain _____________________________________________________________________________________________
Amount owed monthly $________________
Have you applied to Public Housing or Section 8? ____no ____yes, when ___________________, were you accepted? ____no ____yes,
Date of acceptance _____ Waiting list # ______________
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DO YOU HAVE ANY LEGAL ISSUES? Explain (including date, time, reason, and outcome) If you need more space use a separate piece of paper.
Divorce/Separation: _______________________________________________________________________________________________________
Bankruptcy: ____________________________________________________________________________________________________________
Eviction/Foreclosure: ______________________________________________________________________________________________________
Child Custody: ___________________________________________________________________________________________________________
Arrest: _________________________________________________________________________________________________________________
Other: _________________________________________________________________________________________________________________
Have you been convicted of a crime, placed on probation/parole, had to complete community service hours, or are
you currently involved in criminal activity (includes simple misdemeanors)? _______no _______yes, please explain.
Criminal past does not automatically exclude you from consideration for the program. Warning: Not being truthful on
this application will exclude you from consideration.
Please include date of crime, charge, reason, and outcome.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Cause of Homelessness: Please explain
Eviction/Forclosure:_____________________________________________________________________________________________________
Job Loss: _____________________________________________________________________________________________________________
Utility Disconnection:___________________________________________________________________________________________________
New In Town: _________________________________________________________________________________________________________
Fleeing Abuse:_________________________________________________________________________________________________________
Other: _______________________________________________________________________________________________________________
*** EMERGENCY LOCAL CONTACT PERSON (not living with you):
Name _______________________________________________ Address________________________________ City________________________
Zip_________________________________________________ Day phone_________________________ Night phone______________________
Relationship to you ______________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Have you been homeless before?__________________________________________________________________________________________
List shelter /housing programs you have stayed at:__________________________________________________________________________
What are your family’s future goals?______________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Goals for housing?______________________________________________________________________________________________________
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Briefly describe each family member
_______________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
What is needed to stabilize your family? Length of time needed for stabilization?
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Please describe your family’s strengths and weaknesses
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
VERY IMPORTANT! This part must be done for your application to be considered.
In your own words, please describe why you and your family should become participants of the West Des Moines Human
Services Housing Solutions Program. Explain how the program can help you and your family. Include some of you dreams,
hopes and goals.
Use as much paper as needed and attach all pages to your application form.
__________________________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
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_____________________________________________________________________________
_____________________________________________________________________________
___________________________
By signing below We/I hereby certify that the application information provided is true and complete to the best of my/our knowledge and
belief. We understand that failure to provide true and complete information could result in the application not being considered, or
termination from the program if you had already been accepted into the program.
We understand that if we are asked to come in for an interview, it is our responsibility to provide financial information and proof of
homelessness verification. Failure to attend a scheduled interview will result in our application being denied. Lastly, we understand that
applying for the Transitional Housing Program does not mean we will be accepted into the program.
______________________________________________________
SIGNATURE
_________________________
DATE
______________________________________________________
SIGNATURE
_________________________
DATE
***Name
of person who filled out this application (print) ________________________________________
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