HOUSING APPLICATION
Genesis Program/Exodus Program
Please take the time to read this application and complete it to the fullest extent possible. The information you
provide will assist us in determining the stability of your housing situation and your eligibility for our programs.
Your Name
Gender: √ the block
City/State
Today’s Date
F
M
Current Address
Phone Number
Your Birthdate
Who do you Contact when there is
an Emergency?
Their Name
Their Address
Their Phone #
What is your
marital status?
ny
children?
Single
Married
Separated
Is your child in your custody?
Widowed
What age is your child?
Your Basic Needs
Do you currently have enough money to meet your basic
needs (rent, utilities, food, transportation,etc?
Your Current Housing Situation:
Are you homeless right now?
How long have you been
homeless?
Are you staying at a
Shelter right now?
If so, which one?
Check those situations that pertain to you:
Served a legal eviction notice within 30 days
Did not pay utility bills
Did not pay last month’s rent
Doubled with family or friends
Building in bad condition
Overcrowded living situation
Threats of being kicked out/asked to move out
Aging out of foster care
Last Known Address
Landlord’s Name
Street Address
City, State and Zip Code
Monthly Rent Amount
Average Monthly Utility Bill(s) Amount
Landlord’s Phone #
Divorced
(must supply documentation)
Previous Address
Landlord’s Name
Landlord’s Phone #
Street Address
City, State and Zip Code
Monthly Rent Amount
Average Monthly Utility Bill(s) Amount
Have you ever applied for government subsidized housing?
Yes
No
Yes
No
If so, when and where?
Do you have any outstanding fines and/or monies owed?
If so, to whom and how much?
We have to ask you about your MENTAL HEALTH status
Have you ever been treated for a mental health diagnosis?
Have you ever been hospitalized for a mental health issue?
If so, please tell us when that happened and where you received
treatment. Thank you.
Are you on medication(s) for a mental health issue? If so, what are
they and the dosage. Use more room to tell us if necessary. Thank you.
Domestic Violence
Are you homeless due to domestic violence,
abuse or assault in the last 30 days?
Income History
Are you currently working?
Where?
Since when?
How many Hours/Week?
Pay per Hour
Has your income decreased
in the past three months?
Support Network
Do you have relatives that live nearby?
Have you asked relatives or friends to allow you
to live with them until you secure stable housing?
If so, has a police report been made?
Why can’t you stay with family or friends?
Lease Violation Circle Which One Pertains to you
Financial Hardship
Overcrowded
Abusive Relationship
Health Issues
Too unstable or unsafe
Strained relationship
Other, please explains
Arrest History
Have you ever been convicted of a crime?
Please list any past criminal activity including ALL misdemeanors and felonies.
Also include any current outstanding community service, court fines, etc.
This information will NOT disqualify you from entering a PAL Mission program.
A background check will be conducted.
Description of Offense
Date of Offense
Jail Time
Served?
Yes
No
If yes, how long?
Probation/Parole Officer Name
PO Phone #
Next Court Date
Outstanding Community Service or Court Fines – Please Give Amounts.
Use 2nd page if necessary for any additional offenses
Education
What is the highest level of education complete?
Did you graduate high school?
Yes
No
Year Graduated
High School Name
Did you have a GED?
Please explain your educational goals.
Yes
No
Please read the following CAREFULLY, then sign and date below.
The information provided on the previous pages is accurate and honest to the best of my
knowledge. I am aware this is NOT a promise of placement, it is ONLY an application. I
understand a background check will be issued on my criminal activity (if any).
I understand placing false information anywhere on this application may disqualify me from PAL
Mission programs.
I also understand placing false information on this application is grounds for eviction should I
be accepted into a PAL Mission program.
In the event I am accepted into a PAL Mission program, I will be prepared to submit the
following: photo identification, social security card, proof of income, reunification plan and/or
working case plan with JFS (if applicable), a $30 deposit and any other pertinent information as
requested by PAL Mission Staff.
Applicant Signature
Date
PAL Mission Staff
Date