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HomeShare Application

HomeShare ApplicationNeighbor2Neighbor2021-12-21T17:17:59-07:00

HomeShare Application

I am interested as (select one)(Required)

Home Provider

Home Seeker

Applicant Information

Name(Required)

Date of Birth(Required)

Age(Required)

Phone(Required)

Alternate Phone

Consent(Required)

By checking this box, you agree to receive SMS from Neighbor to Neighbor. You may reply "Stop" to opt-out at any time.

Address(Required)

City(Required)

State(Required)

ZIP(Required)

Length of time at address(Required)

Email address(Required)

How did you hear about HomeShare?(Required)

Have you applied to HomeShare before? (If yes, when?)(Required)

Race (choose all that apply)(Required)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Ethnicity(Required)

Non-Hispanic/Latino

Hispanic/Latino

Prefer not to answer

Gender(Required)

Male

Female

Prefer not to answer

Prefer to self-describe

Disabling Condition(Required)

Yes

No

Prefer not to answer

Co-Applicant Information

Co-Applicant Name

Co-Applicant Relationship to Applicant

Co-Applicant Race (choose all that apply)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Co-Applicant Ethnicity

Non-Hispanic/Latino

Hispanic/Latino

Prefer not to answer

Co-Applicant Date of Birth

Co-Applicant Age

Co-Applicant Gender

Male

Female

Prefer not to answer

Prefer to self-describe

Co-Applicant Disabling Condition

Yes

No

Prefer not to answer

Other Household members currently living with you

Name #1

Relation

Age

Name #2

Relation

Age

Name #3

Relation

Age

Name #4

Relation

Age

Name #5

Relation

Age

Household Benefits and Income for all individuals and family members (SSI, TANF, Food stamps, etc.)

Type of Benefit/Monthly Amount

Type of Benefit/ Monthly Amount

Type of Benefit/Monthly Amount

Retirement Income/Monthly Amount

Investment Income/Monthly Amount

Other Income/Monthly Amount

Employment

Name of Employee

Job Title

Name of Employer

Start Date

Average Hours Worked Per Week

Wage

Total Monthly Income

Type of Work

Permanent

Temporary

Seasonal

Contract-Based

Other Employment

Name of Employee

Job Title

Name of Employer

Start Date

Average Hours Worked Per Week

Wage

Total Monthly Income

Type of Work

Permanent

Temporary

Seasonal

Contract-Based

Are you able to handle your own personal care? (bathing, feeding, toileting, transferring, ambulation, taking medication, dressing, etc.)(Required)

Yes

No

Have you ever been convicted of a felony or misdemeanor?(Required)

Yes

No

Are you currently, or have you ever been on probation?(Required)

Yes

No

Have you ever been evicted?(Required)

Yes

No

References: Provide names and phone numbers of 3 people who know you well and will act as a character reference for you. Include full name, phone number, and relationship.

Reference 1 Name(Required)

Reference 1 Phone(Required)

Reference 1 Relationship(Required)

Reference 2 Name(Required)

Reference 2 Phone(Required)

Reference 2 Relationship(Required)

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