Veteran Application Shared Housing Program A safe place. A stronger community. Brighter tomorrows. Honor Support Opportunity 1. Applicant Information Full Name Date of Birth Phone Number Email Address Current Address City State ZIP Code How long have you lived at your current address? Less than 6 months 6–12 months 1–3 years More than 3 years Options: 2. Veteran Information Are you a U.S. military veteran? Yes No Branch of Service Army Navy Air Force Marines Coast Guard Space Force Select branch Approximate Years of Service Are you currently connected with the VA? Yes. No Are you currently working with a VA case manager, social worker, housing specialist, or other referral professional? Yes. No Not sure If yes, name/contact information (if you wish to provide it) Are you currently participating in or applying for HUD-VASH? Currently receiving HUD-VASH Applying for HUD-VASH Have a HUD-VASH voucher Not currently participating Not sure Are you receiving assistance through SSVF or another housing program? Yes. No Not sure 3. Housing History Why are you looking for housing at this time? When do you need housing? Immediately Within 7 days Within 30 days Within 60 days More than 60 days Where are you currently staying? Own home Renting Staying with family/friends Shelter Transitional housing Hotel/motel Temporary housing Other Have you previously lived in shared housing? Yes. No If yes, how was your experience? 4. Financial / Rent Information What is your current source or sources of income? Employment VA benefits Social Security SSI SSDI Pension Other Approximate monthly income Do you currently receive housing assistance? Yes. No Pending If yes, what type? Do you expect to pay your portion of the rent directly? Yes. No Housing assistance will pay some/all of my portion Not sure Do you have any current unpaid rental balance or housing debt that could affect your ability to rent? Yes No If yes, please explain 5. Housing Needs Type of housing needed Shared Housing Private Room Other Do you require any special accommodations? Yes. No If yes, please explain 6. Shared Living Compatibility Do you smoke? Yes. No Do you have pets? Yes. No Are you comfortable with guests/visitors? Yes. No Are you comfortable living with roommates? Yes. No Please share any additional preferences (optional) Yes. No 7. Safety & House Rules Do you agree to follow the house rules? Yes. No Have you had any substance abuse issues? Yes. No Have you had any criminal charges in the past 5 years? Yes. No 8. Emergency Contact Emergency Contact Full Name Relationship to Applicant Parent Spouse Sibling Friend Other Emergency Contact Phone Number Emergency Contact Email Address Emergency Contact Address 9-Referral Information How were you referred to Second Chance Haus LLC? Friend or Family Social Worker VA Representative Community Organization Online Search Website Other Name of Person or Organization Referring You Referral Contact Information (Optional) Additional Referral Details (Optional) 10. Acknowledgement & Signature Applicant Agreement I certify that the information provided in this application is true and complete to the best of my knowledge. Applicant Full Name (Signature) Applicant Signature Date Submitted Send
