Non-Veteran Application Shared Housing Program A safe place. A stronger community. Brighter tomorrows. HOUSING COMMUNITY STABILITY 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. 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 3-Referral Information How were you referred to Second Chance Haus LLC? Friend or Family Social Worker Community Organization Online Search Website Other Name of Person or Organization Referring You Referral Contact Information (Optional) Additional Referral Details (Optional) 4. Acknowledgement & Signature Applicant Full Name (Signature) Applicant Agreement I certify that the information provided in this application is true and complete to the best of my knowledge. Applicant Signature Date Submitted 5. 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? 6. 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 7. Housing Needs Type of housing needed Shared Housing Private Room Other Do you require any special accommodations? Yes. No If yes, please explain 8. Shared Living Compatibility Do you smoke? Yes. No Are you comfortable with guests/visitors? Yes. No Are you comfortable living with roommates? Yes. No Please share any additional preferences (optional) 9. 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 Send
