Housing Help Line – Hope House – Housing Services For The Homeless

Name

First

Last

Social Security Number

Date & Time

Date

Time

Date of Birth

Household Size

Type of Household

Gender

Race (Select 'Primary Race' and 'Secondary Race', if provided)

Ethnicity

Hispanic or Latino
Non-Hispanic or Non-Latino

Have you or anyone in your household served in the Armed Forces

Yes
No

Phone number

Alternate phone number

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Have you ever received assistance from Metro Housing, Hope House or any other HUD housing program in the past?

Yes
No

If yes, when and in what state.

Who referred you?

Monthly Gross Income

Monthly Net Income

Employer

Additional Income

Disabled?

Yes
No

Disabled

Physical
Mental
Developmental

Additional Family Info. (Include Name, Age, Relationship, Type of Income and Income Amount)

Rent Amount

Are you behind in rent?

Yes
No

If yes, how much?

Do you have a current eviction?

Yes
No

Do you have a lease?

Yes
No

Are you behind in your present utilities?

Yes
No

Which utilities?

Gas
Electric
Water

How much do you owe for utilities?

Do you have enough food for the next 5 days?

Yes
No

Do you feel you need a consultation with a lawyer?

Yes
No

Landlord's Name

Landlord's Phone

Is the household income below 200% of the federal povery guidline?

Yes
No

All information is true and correct to the best of my knowledge. (Signature)

Additional details of current housing situation and if/how it is related to COVID-19.

File Upload

Click or drag a file to this area to upload.

Please upload these files if possible: lease/month-to-month occupancy proof; Social Security card for each person; ID for all over 18 years old; birth certificate for each person in the home; proof of income--current/prior to COVID if hours have changed/verification of lost employment; proof from landlord of arrears.

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