Project imPACT Housing Enrollment Form
 

Client Information

Residency Status *
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What Is Your Gender Identity? *
 
Ethnicity *
Race *
 
Do You Have The Following Identifying Documents (Check All That Apply): *

Financial Resources

What Is Your Income Source? *
 

Housing History

Do You Currently Pay Rent? *
Have You Ever Lived In A Transitional Living Facility Before? *

Rental History

Have You Ever Rented Before? *
Have You Ever Been Served A Late Rent Notice? *
Have You Ever Been Evicted? *
Do You Have Any Outstanding Utility Bills? *
Have You Ever Applied For Government-Sponsored Housing? (i.e. Section 8, Shelter Plus Care, SRO) *
Have You Ever Lived In Government-Sponsored Housing? (i.e. Section 8, Shelter Plus Care, SRO) *
Do You Owe Any Debt To A Public Agency (i.e. Housing Authority, child support, etc.)? *
Have You Ever Committed Fraud While Receiving Housing Assistance? *
Have You Had Any Problems With Previous Landlords? *

Community Support Reference

Do You Currently Have A Case Manager At Any Agency? *