Supported Housing For Persons With Disabilities Pre-Application (Page 3 of 4) in pdf

SUPPORTED HOUSING FOR PERSONS WITH DISABILITIES

PRE-APPLICATION

By completing this application you are indicating your interest in securing housing in one of the following projects

which provide housing with support services for persons with disabilities. Support services may include mental health

counseling, medication monitoring and assistance, case management, employment services, money management and

budgeting assistance or support with personal care housekeeping, nutrition and health services.

Please indicate the project(s) for which you have interest in being considered for placement.

The Landing on Villa in Villa Park, IL (Opening in late 2014)

_______ Yes ______ No

Findley Supported Housing in Lombard, IL (Due to open in late 2015) _______ Yes ______ No

Size of unit requested:

Studio Apartment

_______ Yes ______ No

One Bedroom

_______ Yes ______ No

Two Bedroom

_______ Yes ______ No

HEAD OF HOUSEHOLD INFORMATION

Last Name: ________________________________ First Name: ____________________________ Middle Initial: _____

Social Security Number: ____ ____ ____-____ ____-____ ____ ____ ____ Date of Birth: ____ /____ /_____ Sex: M / F

Street Address: _______________________________ City: ______________________ State: _______ Zip: __________

Telephone Number: _____________________________ Alternate Telephone Number: ___________________________

ARE YOU CURRENTLY EMPLOYED?

____Yes ____ No Employer: ___________________________________

Employer’s Street Address: ___________________________City: ___________________ State: ______ Zip: _________

ARE YOU A U.S. CITIZEN?

______ Yes ______No

Alien Reg. # ___________________________________

DO YOU CLAIM ANY OF THE FOLLOWING PREFERENCES?

Residency: Live or work in DuPage County (Work must be permanent, non-temporary _______ Yes ______ No

Household has at least one member who is elderly (age 62 or over) or disabled

_______ Yes ______ No

Working: At least one person works 30 hours per week

_______ Yes ______ No

Special Needs: Head of Household is a Veteran, Victim of Domestic Violence, and Family Self-Sufficiency Participant

or is in a HUD approved demonstration project.

______ Yes ______ No

Involuntary Displacement: Household has been displaced due to a government action or natural disaster declared by the

President

_______ Yes ______ No

Homeless: Head of Household is transitioning from a homeless services program (transitional or permanent supportive

housing) or is residing in a shelter or other location not fit for human habitation.

_______ Yes ______ No

INFORMATION ABOUT SPOUSE

Last Name: ________________________________ First Name: ____________________________ Middle Initial: _____

Social Security Number: ____ ____ ____-____ ____-____ ____ ____ ____ Date of Birth: ______ /_______ /_________

Supported Housing For Persons With Disabilities Pre-Application Page 3

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