"Referral Form Template - Permanent Supportive Housing Program" - Macon, Georgia (United States)

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Download "Referral Form Template - Permanent Supportive Housing Program" - Macon, Georgia (United States)

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Referral Form
Permanent Supportive Housing Program
Macon, GA 31217
Office Number- 478-803-7732
Application For Occupancy
Date Application Received:
Client I.D. :
Staff Initials:
Applicant Information
Which Housing Option are you applying for? Please check one
Shelter Plus Care w/ a preference for: First Neighborhood___ Third Neighborhood__ Bayside__
Transitional Housing (females only) __ HOPWA __ Grove Park Village__
Name (as it appear on Social Security Card):
Date of Birth:
Place of Birth:
SS#
Driver’s License No:
Driver’s License State:
Expiration Date:
Vehicle License No:
Vehicle Make/Model:
Vehicle Year/Color:
Phone:
Alternate Phone:
Email address:
Marital Status:
Spouse’s Name:
Are You a Full-Time Student?
Other Names Used in the Past:
Current Residence or Current Condition of Homelessness:
Current Address:
How long?
City
State:
Zip Code:
HUD defines a chronic homeless person as an individual who is homeless and lives in a place not meant for human
habitation, a safe haven, or in an emergency shelter; and has been homeless and living or residing in a place not meant
for human habitation, a safe haven, or in an emergency shelter continuously for at least one year OR on at least four
separate occasions in the last 3 years AND can be diagnosed with one or more of the following conditions; substance
abuse disorder, serious mental illness, or developmental disability. Does the client meet this criterion? __Yes__ No
Explain the condition of homelessness. REMINDER: Only persons coming from an emergency shelter, the street, or
places not meant for human habitation are considered eligible for Shelter Plus Care.
What resources does the client have to address their homeless situation i.e. adequate income, job, friends or relatives?
Previous Address:
How long?
City
State:
Zip Code:
Previous Residence:
Previous Address:
How long?
City
State:
Zip Code:
Employment Information
Current Employer:
Employer Address:
How long?
Phone:
E-mail:
Fax:
Referral Form
Permanent Supportive Housing Program
Macon, GA 31217
Office Number- 478-803-7732
Application For Occupancy
Date Application Received:
Client I.D. :
Staff Initials:
Applicant Information
Which Housing Option are you applying for? Please check one
Shelter Plus Care w/ a preference for: First Neighborhood___ Third Neighborhood__ Bayside__
Transitional Housing (females only) __ HOPWA __ Grove Park Village__
Name (as it appear on Social Security Card):
Date of Birth:
Place of Birth:
SS#
Driver’s License No:
Driver’s License State:
Expiration Date:
Vehicle License No:
Vehicle Make/Model:
Vehicle Year/Color:
Phone:
Alternate Phone:
Email address:
Marital Status:
Spouse’s Name:
Are You a Full-Time Student?
Other Names Used in the Past:
Current Residence or Current Condition of Homelessness:
Current Address:
How long?
City
State:
Zip Code:
HUD defines a chronic homeless person as an individual who is homeless and lives in a place not meant for human
habitation, a safe haven, or in an emergency shelter; and has been homeless and living or residing in a place not meant
for human habitation, a safe haven, or in an emergency shelter continuously for at least one year OR on at least four
separate occasions in the last 3 years AND can be diagnosed with one or more of the following conditions; substance
abuse disorder, serious mental illness, or developmental disability. Does the client meet this criterion? __Yes__ No
Explain the condition of homelessness. REMINDER: Only persons coming from an emergency shelter, the street, or
places not meant for human habitation are considered eligible for Shelter Plus Care.
What resources does the client have to address their homeless situation i.e. adequate income, job, friends or relatives?
Previous Address:
How long?
City
State:
Zip Code:
Previous Residence:
Previous Address:
How long?
City
State:
Zip Code:
Employment Information
Current Employer:
Employer Address:
How long?
Phone:
E-mail:
Fax:
City:
State:
ZIP Code:
Position:
Supervisor’s Name
Monthly Income:
Other Sources of Income
Amount:
How often received:
Social Security:
SSI:
AFDC:
Unemployment Benefits:
Child Support:
Pension:
Food Stamps:
Employment:
Other:
Assets
Cash on Hand:
Banking Institution:
Checking Account No:
Balance:
Banking Institution:
Savings Account No:
Balance:
Banking Institution:
IRA Account No:
Balance:
Real Estate (Description):
Value:
Monthly Income:
Other:
Have You Disposed of Any Assets For Less Than Fair Market Value Within the Last Two Years?
If Yes, Explain:
Spouse’s Application Information (if applicable)
Name:
Date of Birth:
Place of Birth:
Social Security No:
Driver’s License No:
Driver’s License State:
Expiration Date:
Vehicle Make/Model:
Vehicle Year/Color:
Vehicle License No:
Phone:
Alternate Phone:
Email address:
Spouse’s Name:
Are You a Full-Time Student?
Other Names Used in the Past:
List all Previous Addresses for the Past 5 Years:
Previous Residence: Name of Owner, Apartment Community, Mortgage Company:
Previous Address:
How long?
City
State:
Zip Code:
Employment Information
Current Employer:
Employer Address:
How long?
Phone:
E-mail:
Fax:
City:
State:
ZIP Code:
Position:
Supervisor’s Name
Monthly Income:
Previous Employer:
Employer Address:
How long?
Phone:
E-mail:
Fax:
City:
State:
ZIP Code:
Position:
Supervisor’s Name
Monthly Income:
Other Sources of Income
Amount:
How often received:
Social Security:
SSI:
AFDC:
Unemployment Benefits:
Child Support:
Pension:
Food Stamps:
Employment:
Other:
Assets
Cash on Hand:
Banking Institution:
Checking Account No:
Balance:
Banking Institution:
Savings Account No:
Balance:
Banking Institution:
IRA Account No:
Balance:
Real Estate (Description):
Value:
Monthly Income:
Other:
Have You Disposed of Any Assets For Less Than Fair Market Value Within the Last Two Years?
If Yes, Explain:
Other Occupants in Household
Persons who are not listed below are not authorized to live in the apartment.
Name:
Date of Birth:
Sex:
Relationship:
SSN:
Name:
Relationship:
Date of Birth:
Sex:
SSN:
Name:
Date of Birth:
Sex:
Relationship:
SSN:
Name:
Date of Birth:
Sex:
Relationship:
SSN:
Criminal History
Have you or any member of your household been convicted of a violent crime within the last 10 years?
Have you or any member of your household been convicted of a non-violent crime within the past 5 years?
Have you or any member of your household been involved in the sale, manufacture or distribution of a controlled
substance?
Have you or any member of your household been arrested or convicted for illegal use, sale, distribution or manufacture
of a controlled
substance?
Are you or any member of your household a registered sex offender? If yes, in which state:
Have you or any member of your household been evicted from a Federally Assisted property within the last 3 years?
If yes, when?
What property?
Please describe your current legal status:
Please list all states that you have lived in:
Emergency Information
Name:
Address:
Phone Number:
Relationship:
Are you a veteran?
_____Yes
_____No
Accessibility (For Eligibility Purposes Only)
E
Are you or anyone in your household disabled/handicapped? If so, who?
Do you or any member of your household have a need for an accessible unit? If so, please describe the need for an
accessible unit:
Please describe your current River Edge outpatient services, frequency, and compliance level.
Please describe any physical health problems that you have.
Agreement and Authorization Signature
I affirm that the information given in this application is true and correct. I understand that if any of the
information provided is false, misleading or incomplete, management may decline my application, or if move-
in has occurred; terminate my lease and evict me and my household. Do not use white-out on this form, please
line through the error and initial the change. I understand that it is a crime to knowingly provide false
information for the purpose of obtaining or maintaining occupancy in and/or for the purpose of securing a
lower rent in a subsidized housing development. I authorize Management to make any and all inquiries to
verify this information either directly or through information exchanged now or later with rental and credit
screening services, previous and current landlords, law enforcement agencies or other sources of information
released to appropriate Federal, State, or local agencies. The applications selection process will be in
accordance with the Second Neighborhood Tenant Selection Plan. I affirm that the apartment unit applied for
will be my/our permanent residence. I affirm further that I do not and will not maintain a separate subsidized
rental unit in a different location.
Applicant’s Signature
Date
Co-Applicant’s Signature
Date
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