Office Use Only Unit Size Requested Unit Number Targeted Move-In Date Date Received Time Received _U__p__t_o_w__n___A__p__a_r_t_m__e__n__t_s_______________________ _3__0_1___N__o__r_th___C__e__n_t_e__r__S__tr_e__e__t_N__W______________ _S__i_lv__e_r__L__a__k_e__,_M___N___5_5__3__2_1____________________ _P__h__:_(_5__0__7_)__6__2_5__-_0__2_4__9________________________ APPLICANT INFORMATION Applicant Name (Head of Household): Address: Social Security Number: Date of Birth: [ ] Male [ ] Female [ ] Decline Applicant Phone #: Applicant Email: Alternate Phone #: Alternate Email: Emergency Contact: List All Other Household Members First MI Last Relationship to Head Date of Birth Male/Female/ Decline to Answer Social Security Number [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline Primary Language: Do you require an interpreter? [ ] Yes [ ] No How did you hear about this housing? [ ] Online [ ] Newspaper [ ] Local Agency [ ] Drive By [ ] Resident Referral [ ] Other What is the combined gross monthly income of all household members? $ ADDITIONAL HOUSEHOLD MEMBERS CURRENT HOUSING STATUS How long have you lived at your current address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: Do all adult household members live at this address?........................................................................................................................ [ ] Yes [ ] No If NO, include additional adult household’s current address and contact information on a separate piece of paper. PREVIOUS HOUSING STATUS Your previous address: How long did you live at your previous address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: List every state in which each household member has lived: ELIGIBILITY INFORMATION
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