Client Information

Current Address (If Experiencing Homelessness, Write "Homeless")

First Name *

Last Name *

AKA (Alias):

City

State

Zip Code

Current Mailing Address (Please include Address, City, and Zip Code)

Residency Status *

US Citizen

Legal Resident

Undocumented

Phone Number *

Date of Birth * +

Age *

Social Security Number (Last 4) *

Email Address

What Is Your Gender Identity? *

Male

Female

Transgender Male/Trans Man/FTM

Transgender Female/ Trans Woman/MTF

Genderqueer, Neither Exclusively Male nor Female

Additional Gender Category or Other, Please Specify Additional Gender Category or Other, Please Specify

What Is Your Sexual Orientation? *

Ethnicity *

Hispanic

Not Hispanic

Race *

Do You Have The Following Identifying Documents (Check All That Apply): *

Financial Resources

What Is Your Income Source? *

Total Monthly Income *

Where Are You Employed?

Housing History

Current Housing Status *

Other (specify)

Do You Currently Pay Rent? *

Yes

No

How Much Rent Do You Pay Per Month?

Have You Ever Lived In A Transitional Living Facility Before? *

Yes

No

What Transitional Living Facility Have You Lived In Before?

Where did the you spend most of your nights in the past 30 days? *

Other (specify)

Where did the you spend last night? *

Other (specify)

Rental History

Have You Ever Rented Before? *

Yes

No

Unsure

Have You Ever Been Served A Late Rent Notice? *

Yes

No

Unsure

Have You Ever Been Evicted? *

Yes

No

Unsure

Do You Have Any Outstanding Utility Bills? *

Yes

No

Unsure

Have You Ever Applied For Government-Sponsored Housing? (i.e. Section 8, Shelter Plus Care, SRO) *

Yes

No

Unsure

Have You Ever Lived In Government-Sponsored Housing? (i.e. Section 8, Shelter Plus Care, SRO) *

Yes

No

Unsure

Do You Owe Any Debt To A Public Agency (i.e. Housing Authority, child support, etc.)? *

Yes

No

Unsure

Have You Ever Committed Fraud While Receiving Housing Assistance? *

Yes

No

Unsure

Have You Had Any Problems With Previous Landlords? *

Yes

No

Unsure

Community Support Reference

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

Yes

No

Agency Name *

Case Manager Name

Case Manager Telephone Number

Name of a Personal or Professional Reference *

Telephone Number of Reference *

Valid ID/DL	CA ID/DL	SS Card
Birth Certificate	Permanent Resident ID	TB Clearance (Last 12 Months)
Proof of Income/Verification of Benefits	DD214 (For Veterans)	Certification of Homelessness
Disability Certification	In Progress To Obtain Documents

Work/Employment	Unemployment
Disability/SSI	Family/Friends
General Relief (GR)	Veteran's Benefits
Other (specify) Other (specify)