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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