Family Self-Sufficiency/homeownership Program Interest Form printable pdf download

Family Self-Sufficiency/homeownership Program Interest Form

FAMILY SELF

FAMILY SELF- - - - SUFFICIENCY/HOMEOWNERSHIP PROGRAM

SUFFICIENCY/HOMEOWNERSHIP PROGRAM

INTEREST FORM

Name: ________________________________ Social Security Number: _________________

Address: _______________________ City: _______________________ Zip Code: ________

Telephone: (Home) _________________ (Work) _______________ (Cell) ________________

Are you interested in FSS ______ Homeownership ______ or Both Programs ______?

Please check all that apply:

1. How did you hear about the FSS / Homeownership programs?

( ) Self Referral

( ) Relocation/Transfer Briefing

( ) FSS Case Manager

( ) Section 8 Case Manager

( ) Public Housing Manager

( ) Friend

( ) Other _______________

2. Have you been invited or ever attended a FSS or Homeownership orientation in the past?

If yes, did you attend? Yes ( ) No ( )

Did you enroll into the FSS program? Yes ( ) No ( )

Did you receive a Homeownership Voucher to search for a home? Yes ( ) No ( )

3. Please check any current needs you may have:

( ) GED

( ) Literacy Classes

( ) Financial / Credit Counseling

( ) ESL

( ) Drug Counseling

( ) Adult Basic Education

( ) College

( ) Family Counseling

( ) Business Ownership

( ) Child Care

( ) Employment

( ) Survival Skills

( ) Parenting Skills

( ) Transportation

( ) Health Services

Per the FSS Contract of Participation (COP), the client must have a current reexamination / interim

completed within 120 days prior to the execution of the COP.

____________________________________

_____________________________

Signature

Date

OFFICE USE ONLY

Client Number: ________________________

Last Re-exam / Interim: _____________________

FSS Status: ____________________________

Orientation Date: __________________________

FSS / HCVHP Case Manager: ____________________

Attended Orientation Yes _____ No ______

Hearing impaired assistance is available in Alabama by dialing 711

Crime and Fraud hotline – call: 334-206-7711

Family Self-Sufficiency/homeownership Program Interest Form

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