Housing Navigation Referral "*" indicates required fields Client Name* First Last Date* MM slash DD slash YYYY Client Email* Client Phone Number*Name of person filing application*Position/role to Nonprofit/Organization*Phone Number*Email* Client Address Street Address Apartment Number City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AgeBirthdate MM slash DD slash YYYY Total number of adults in household*Number of kids in household*Ages of kidsAre you married?* Yes No Separated Widowed Divorced Are you or any household member a Veteran?* Yes, myself Yes, a household member No Are you or any household member disabled?* Yes, myself Yes, a household member No Do you currently have a Housing Choice/Section 8 or VASH Voucher?* Yes No Do you or any household members have health insurance?* Yes No If yes, what kind?Are you enrolled in Healthy Opportunities Pilot (HOP)? Yes No What is your current housing situation?* Owner Renter Staying with family Homeless Other If other, please explain:How long have you been in your current housing situation?*If you are a renter, do you have a current lease with your name on it? Yes No Unsure N/A Landlord's Name First Last Landlord's PhoneMonthly Rent PaymentMonthly Utilities TotalWhat is your preferred outcome with your rental? Remain there Move to new housing If you are a homeowner, do you have a current deed with your name on it? Yes No Unsure N/A Monthly mortgage paymentMonthly utilities paymentPlease check all forms of income you/your household receive:* Employment Unemployment SSD/SSI Pension Child Support Other If other, please explainTotal monthly household income before expenses:*Please check your primary reason(s) for requesting Housing Navigation support:* Eviction prevention Foreclosure prevention Utility assistance Rental assistance Questions about my lease Problem with my landlord Assistance applying for a new rental Assistance finding a rental Major home repairs Minor home repairs Health issues Other If other, please explainPhoneThis field is for validation purposes and should be left unchanged.
