West Des Moines Human Services/Transitional Housing Program

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

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 +_____ /// 1 2 3 4 5 6 7 8 9 10 11 12 +_____

High School Diploma?______- GED?______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______

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 $ ______

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 # ______

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?______

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.

______

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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