Tree of Life Ministries

Tree of Life Ministries

Transitional Housing Application

PLEASE COMPLETE ALL QUESTIONS BELOW. If the question is not applicable, please write ‘NONE’ or ‘N/A’.

Personal Information

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Name:______

Social Security Number: ______

Date of Birth: ______

Age: ______

Name: ______
Social Security Number:______

Date of Birth:______

Age: ______

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Please list the individuals that will reside in the home:

Name / Date of Birth / Relationship to you / Custody / Social Security Number

Address: ______

City/State/Zip: ______

Daytime Phone: ______Evening Phone: ______

Cell Phone: ______Email: ______

Marital Status: ______Race: ______Hispanic? (Y/N): ______

Are you a U.S. Citizen? ______Immigrant Status: ______

Briefly explain your situation and the circumstances contributing to your homelessness:

______

Emergency Contact: ______Phone #: ______

Relationship to you: ______

Emergency Contact: ______Phone #: ______

Relationship to you: ______

Housing History

Current Residence:

Address: ______

City/State/Zip: ______

Owner/Manager Name: ______

Owner/Manager Phone #: ______

Dates of occupancy: From______to ______

Reason for leaving: ______

Please list other previous addresses for the last 3 years:

1. Address: ______

City/State/Zip: ______

Owner/Manager Name: ______

Owner/Manager Phone #: ______

Dates of occupancy: From______to ______

Reason for leaving: ______

2. Address: ______

City/State/Zip: ______

Owner/Manager Name: ______

Owner/Manager Phone #: ______

Dates of occupancy: From______to ______

Reason for leaving: ______

3. Address: ______

City/State/Zip: ______

Owner/Manager Name: ______

Owner/Manager Phone #: ______

Dates of occupancy: From______to ______

Reason for leaving: ______

Have you ever been evicted? (Y/N)______

Have you ever been denied a renewal of lease? ______

Legal History

Are you or anyone in the household presently on probation? (Y/N) ______

Date probation ends: ______

Do you or anyone in your household have any pending charges? (Y/N) ______Court dates: ______

List all felony and misdemeanor charges (current and previous) with dates and dispositions: ______

List any protective orders in place: ______

Transportation

Do you have a valid driver’s license? ______What State? ______

Has your license ever been suspended? ______Explain the circumstances: ______

Please list all vehicles that you own:

Year ______Make ______Model ______

License Plate #: ______Is this vehicle insured? ______

Year ______Make ______Model ______

License Plate #: ______Is this vehicle insured? ______

Education

What is the highest level of education you have completed? ______

Do you have a: High School Diploma? ______GED? ______Other degree? (BS, MS, PhD)? ______

Do you have any special Licenses or Certificates? ______

Employment

Current Employer: ______Start Date: ______

Address: ______

City/State/Zip: ______

Supervisor: ______Phone #:______

Position: ______Hours/week: ______

Rate of Pay ______Frequency of Pay ______

Spouse:

Current Employer: ______Start Date: ______

Address: ______

City/State/Zip: ______

Supervisor: ______Phone #:______

Position: ______Hours/week: ______

Rate of Pay ______Frequency of Pay ______

Please List two previous employers:

Employer: ______Start Date: ______End Date: ______

Address: ______

City/State/Zip: ______

Position: ______Reason for Leaving: ______

Employer: ______Start Date: ______End Date: ______

Address: ______

City/State/Zip: ______

Position: ______Reason for Leaving: ______

What is the longest period you have held a job? ______

Financial

Have you ever filed bankruptcy? ______If so, when? ______Are you considering filing for bankruptcy? ______Why? ______

Are there any debts that you owe that do not appear on your credit report? ______

______

Are there any items on your credit report that you are in the process of disputing? ______

Do you currently have a wage garnishment, active or pending? ______Amount ______Reason______

List all current bank accounts, either joint or individual that you have. Please indicate if you checking or savings.

Account Type / Name on Account / Financial Institution / Balance / Date opened

Please note, this information will not prohibit you and your family from being able to lease the TOL property, but will help your Case Manager in assisting you to establish a financial plan.

Income / "X" if receive / Monthly Amount
Salary
Child Support
TANF
Food Stamps
WIC
Gas Voucher/Bus Tokens
Veterans Benefits
SSDI
SSI
Social Security
Unemployment Benefits
Worker's Compensation
Other (please explain)
Total Income / $

Please check all that apply and list the monthly amount:

Please provide the following information:

Income / Amount / Expenses / Amount
Salary / Mortgage/Rent
Child Support / Property Taxes
TANF / Repairs
Social Security / Maintenance
SSI / Furniture
Veterans Benefits / Home/Renters Insurance
Other / Electricity
Other / Oil/Gas/Heat
Other / Water/Sewer
Cable TV
Gross Income / Internet
Telephone
Taxes (subtracted) / Trash Removal
Groceries
Net Income / Meals Out
Diapers/Wipes
Less Expenses / Auto Payment
Auto Insurance
Net / Gasoline
Car Maintenance
Tags/Inspection
Benefits / Property Tax
Food Stamps / Health Insurance
Child Care Assistance / School Supplies
Gas Vouchers / Lunch Money
Other Transportation / Allowance
WIC / Lessons/Sports
Other / Childcare Expenses
Other / Medicines/Rx
Other / Co Pays/Doctor
Church/Charity
Holidays/Birthdays
Cosmetic Services
Clothing
Cleaning/Laundry
Uniforms
Savings
School Loans
Credit Card totals
Payday/Title Loans
Other
Other
Other
Total Expenses / $

List any debt you may have including credit cards, medical bills, car loans, utility bills, overdrawn bank accounts, returned/unpaid checks, pay day or title loans, or money owed to friends/family:

Name / Type of Debt / Total Debt / Monthly Payment / Balance Due

Medical

Have you ever had any serious physical illness? ______Explain: ______

______

Are you currently receiving treatment/medication for this illness? ______

On the back of this form, please list current medications (name of medication and dosage) and who prescribed each medication.

Have you been prescribed any medications that you are not taking? Please list below and state the reason you are not taking these:

______

What medications have you taken in the past that you are no longer taking? Continue on the back of this form as necessary:

______

Are you insured? ______

Have you ever had a serious accident or trauma? ______Explain: ______

______

Have you ever been hospitalized for mental, emotional, or stress related problems?

______

Have you been seen by or are currently working with a counselor or any mental health professional? ______
______

Do you have a history of substance abuse? ______
______

Have you been through a substance abuse rehabilitation program or attend AA/NA?

______

Please answer the following questions:

List 3 goals you want to accomplish during this one-year program:

1)

2)

3)

How do you think that Tree of Life’s Transitional Housing Program can help you and your family? ______

By signing this document, you believe that the information that you provided about yourself and your household throughout this form are correct.

______

SignatureDate

I understand and agree that:

All information I have provided may be verified. I agree to release from liability any and all persons or organizations that provide information regarding me, including these persons I have listed as references. I do hereby agree to indemnify and hold harmless, Tree of Life Ministries of Purcellville, its employees, representatives and agents from any claims or causes or action relating in any manner to the verification of or attempts to verify the information provided, attempts to contact references or conversations with any references. I understand that any information received will not be disclosed to me, and I hereby waive any right I have to inspect any information provided about me by any person or organization identified by me on this form.

The information contained in this application is correct to the best of my knowledge. I hereby authorize Protect My Ministryand its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Protect My Ministryor its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I hereby release Tree of Life Ministries, Protect My Ministry, the Social Security Administration, and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

I further state that I have carefully read the foregoing release and know the contents thereof and voluntarily sign this release as my own free act. This is a legally binding agreement which I have read, understood and accept. By signing this form, I certify and affirm that the information I have given is true, complete and correct in all respects.

Applicant’s Name (please print):______

Applicant’s Signature: ______Date: ______

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