Independent Living Housing Application

Date

Time

AM/PM

Name

First

Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

S.S. #

Monthly Household Income

Source of Income

Describe your current housing situation

List all family members including yourself

Name

Age

Number of Bedrooms needed

Are you able to perform daily living activities, cleaning, paying bills, taking medication, etc.?

Are you physically or mentally handicapped?

Describe your disability:

Are you now or have you ever received mental health services?

What is your diagnosis?

Have you or any member of your household ever been convicted of a felony?

What were the charges?

Have you ever received treatment for drug or alcohol abuse?

List places of residence for the past five years

Address

Landlord & Phone Number

Signature(Required)

1-800-611-7757