Perry Housing Partnership Transitional Housing Program APPLICATION FOR ADMISSION

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1 Perry Housing Partnership Transitional Housing Program APPLICATION FOR ADMISSION DATE OF APPLICATION DATE OF INTERVIEW NAME DATE OF BIRTH SS# SPOUSE NAME DATE OF BIRTH SS# CHILDREN: NAME DATE OF BIRTH SS# NAME DATE OF BIRTH SS# NAME DATE OF BIRTH SS# NAME DATE OF BIRTH SS# NAME DATE OF BIRTH SS# NAME OF REFERRAL HOUSING HISTORY: WHERE ARE YOU LIVING NOW HOW LONG CAN YOU STAY THERE DO YOU RENT OR ARE YOU LIVING WITH FAMILY / FRIENDS HAVE YOU BEEN SERVED WITH AN EVICTION NOTICE YES NO ADDRESS OF LAST PERMANENT RESIDENCE DATE LEFT REASON FOR LEAVING HAVE YOU EVER APPLIED AND/OR LIVED IN TRANSITIONAL HOUSING BEFORE YES NO IF SO, WHEN REASON FOR LEAVING HAVE YOU EVER STAYED IN A SHELTER BEFORE YES NO WHERE HOW LONG DID YOU STAY HAVE YOU EVER LIVED IN HUD HOUSING YES NO WHERE WHEN ARE YOU ON THE HUD LIST CURRENTLY YES NO IF SO, WHERE IF NOT, ARE YOU ELIGIBLE FOR HOUSING YES NO IF NO, WHY NOT

2 DRIVERS LICENSE # STATE EDUCATION & EMPLOYMENT HISTORY GED HIGH SCHOOL GRADUATE COLLEGE GRADUATE SOME COLLEGE (Y/N) NUMBER OF SEMESTERS LAST GRADE COMPLETED TRADE OR VOCATIONAL SCHOOL DO YOU OR YOUR SPOUSE CURRENTLY WORK YES NO IF SO, WHERE HOW LONG HAVE YOU BEEN EMPLOYED THERE PLEASE LIST YOUR PAST 3 EMPLOYERS AND DATES OF EMPLOYMENT: 1) 2) 3) CURRENT INCOME: Cash Assistance Amount $ Child Support Amount$ Social Security / Disability Amount $ Employment Amount$ VA Benefits Amount $ Other Amount$ (Specify)_ OTHER BENEFITS: Medical Assistance Card Private Health Insurance Food Stamps Monthly Amount $ Other (Specify) HAVE YOU RECEIVED ANY OTHER FINANCIAL OR LIVING ASSISTANCE IN THE PAST 3 MONTHS YES NO IF SO, WHAT ASSISTANCE AND WHERE IF YOU ARE A VICTIM OF DOMESTIC VIOLENCE, PLEASE ANSWER THE FOLLOWING QUESTIONS: 1.How do you describe the current status with your abuser 2.Do you have a Protection From Abuse (PFA) order from your abuser YES NO HAVE YOU EVER BEEN ARRESTED AND/OR CONVICTED OF A CRIME YES NO IF SO, EXPLAIN AND INCLUDE DATES

3 HAVE YOU RECENTLY BEEN RELEASED FROM ONE OF THE FOLLOWING: Name and Address of Facility Prison Drug/Alcohol Rehab. Hospital Other ARE YOU CURRENTLY IN COUNSELING YES NO WHERE PLEASE LIST A NAME AND EMERGENCY CONTACT NUMBER: NAME NUMBER PLEASE LIST A WAY THAT YOU CAN BE CONTACTED WHEN A ROOM BECOMES AVAILABLE: I certify that the above information is true and correct to the best of my knowledge. I also understand that providing incorrect information could result in my not being accepted into the Perry Housing Partnership s Transitional Housing Program. My signature authorizes Perry Housing Partnership and its contracted employees to make contact with the individuals and organizations listed above for the purpose of providing service to me and or my family. Signature Date *Note: Please fill out the confidential release of information on the last page. ** Note: A criminal background check is mandatory for admission to this program. If you are accepted into the program, we will pay $10.00 for you to get the criminal background check done. You will then be given a specific amount of time to pay the $10.00 back. *** Note: If your criminal check comes back with information that you did not provide to us, you will be recommended for immediate discharge.

4 PERRY HOUSING PARTNERSHIP CONFIDENTIAL RELEASE OF INFORMATION AGREEMENT I permit Perry Housing Partnership to contact the agencies and/or persons listed below in order to request information that may be used for determining my eligibility for the program. This information may also be used for developing an effective and appropriate Service Plan if I am accepted into the program. I understand that all information, once obtained, will be held strictly confidential and maintained in a secured area. AGENCY CASEWORKER DPW Assistance Office Children and Youth Services County Probation/Parole MH/MR Legal Services Social Security Administration Perry County Transportation Rental Assistance Office Perry County Family Center Counseling Agency (Specify) Other (Specify) This release is valid from To Client Signature Date Staff Signature Date

5 SUPPORTIVE HOUSING CRIMINAL RECORD FORM **PLEASE NOTE: ALL QUESTIONS MUST BE ANSWERED COMPLETELY.** 1) Have you or any member of your household ever been arrested, charged, convicted of or plead guilty to a crime? (All grades including felonies, misdemeanors, summary offenses that only resulted in fines, etc. Do not include traffic offenses.) YES NO Please mark off any that apply to you: Retail Theft Burglary Robbery Simple Assault Disorderly Conduct Harassment Aggravated Assault Stalking Criminal Mischief Vandalism Escape Riot Terroristic Threats Arson Rape Murder Manslaughter (Vol. or Invol.) Recklessly Endangering a person Endangering the welfare of a child Unlawful Restraint False Imprisonment Firearm not to be carried w/out a license Incest Sexual Abuse of children Prostitution of a minor Solicitation of minors to traffic drugs Drug Possession Delivery of Drugs Use/Poss. of Drug Paraphernalia Public Drunkenness DUI Bad Checks Theft by deception Prostitution Other charges not listed above 2) Are you or any member of your household currently charged with any crime? YES NO If you answered yes to the first or second question, marked any of the charges above, or have been charged with something not listed above, please list nature of crime, approximate date, and place of conviction: 3) Are you or any member of your household subject to a lifetime sex offender registration requirement in any state? YES NO Signature Date

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