Form Test Page – Mary Rose Mission

Name

First Last

Phone

Date of Birth

Age

Email Adress

What is your sex?

Emergency Contact

Name

Relationship

Phone

Family Status

Children Name(s)

Child(s) birth date

Please mark all that apply:

Are you currently homeless?*

Yes

Are you being evicted withing the next 7 days?*

Yes

Income Sources per month (Check all that apply):

Child Support Amount

Workers Compensation amount

Employer Wages Amount

SSDI Amount

Pension Retirement Amount

Food Stamps Amount

Medicaid Amount

Medicare Amount

Retirement Disability Amount

VA Benefits Amount

Public Assistance Amount

Alimony Amount

Railroad Retirement Amount

Contributions from others Amount

Rental Income Amount

SSI Amount

Unemployment Benefits Amount

Self Employment Amount

TANF Amount

State Disability Amount

Other Amount

Are you a Veteran?

Yes

if Yes Vetran Status of Discharge

If Yes Vetran Date of Discharge

Are you and/or anyone in your household a domestic violence offender?

Yes

Please enter the highest level of education completed

You are not required to answer whether you have a disability however, it can assist us in providing necessary accommodations you need. If yes, please list:

Do you have any outstanding medical bills?

Yes

outstanding medical bills? If yes, please explain

Do you have a checking and/or savings account?

Yes

checking and/or savings account? If yes, list:

Do you pay childcare expenses?

Yes

If yes, how much per month? $

Do you currently owe money or any type of claim to a landlord, Section 8 or any other Housing Authority?

Yes

If YES, how much $

Have you ever been evicted or threatened with eviction in the last five years?

Yes

If yes, please give details (including dates)

Please list and explain ALL police records, arrest, charges, current warrants and city/state and date of occurrence (even if dismissed):

1. Please explain why you think that the Mary Rose Mission Guest House is the right place for you to live?

2. Why do you think you are a good candidate for residency and for the program? What concerns do you have with participating in the program or living at Mary Rose Mission Guest House?

3. What are your goals for your future?

4. How do you expect to accomplish these goals? How do you believe the program at Mary Rose Mission can help you obtain these goals?

If I am accepted as a resident, I understand that this application becomes part of my Program Agreement and that any false or misleading statements or deliberate omission of information on the application will be considered a breach of my Agreement and will make ineligible for the program.The Mary Rose Mission Guest House shall not discriminate in the provision of housing on the grounds of race, color, creed, religion, sex, disability, sexual orientation, familial status or national or regional origin.Please review the information listed on this form and sign below. I do hereby swear and attest that all of the information above is true and correct. I understand that any change in source of income, new or additional sources of income must be reported within 14 days of such change. Reporting requires that you provide verification of information to the Mary Rose Mission Staff.PLEASE BE SURE YOU HAVE ANSWERED ALL QUESTIONS Otherwise, we will be unable to process your information

PLEASE BE SURE YOU HAVE ANSWERED ALL QUESTIONS
Otherwise, we will be unable to process your information

Signature

Date
MM slash DD slash YYYY

Print Name

Guest House Code (office use)

MARY ROSE MISSION GUEST HOUSE

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