PERSONAL INFORMATION
If yes, then provide:
CURRENT HOMELESS STATUS:
Tell us about your last permanent address(where you last lived for 90 days or more):
Please list all states that you have lived in since the age of 18:
EMPLOYMENT:
If not employed, how long did you work on last job:
Income from work & other sources:
Non-Cash Benefits
EDUCATION:
CHILDREN (for minors up to age 17):
Total number of children:
DOMESTIC VIOLENCE:
HEALTH INFORMATION:
DRUGS:
SUBSTANCE USE:
CRIMINAL BACKGROUND:
ANSWER THE FOLLOWING QUESTIONS IN DETAIL(attach an additional sheet if necessary):
What steps have you taken, so far, to prevent you from becoming homeless?
Once you obtain housing, what are your:
EMERGENCY CONTACT:
REFERENCES
(List people, unrelated to you, who we can contact for references.)
Personal/Professional Reference:
Personal/Professional Reference:
Personal/Professional Reference:
I give Project Hope permission toCONTACT ALL REFERENCES &run a CRIMINAL BACKGROUND CHECK (see pages13& 14 Fair Credit Reporting Act). I understand that if I fail to provide written permission, my application will not be processed. I further understand that I have been provided a copy of the agencies Privacy Practices and have read and understand them.
ATTEST OF INFORMATION
I attest that all the information provided in this application is honest and accurate to the best of my knowledge. I understand that any deliberate misrepresentation of the information could result in my being denied acceptance into or expelled from transitional housing.
Address & Employment History
List the places you have resided in the past 5 years.
Dates resided
Dates resided
Dates resided
Dates resided
Dates resided
Dates resided
Dates resided
List the places you have been employed in the past 5 years.
Present Employer:
1. Previous Employer
2. Previous Employer:
3. Previous Employer:
4. Previous Employer:
5. Previous Employer:
A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT
The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). Most CRA’s are credit bureaus that gather and sell information about you – such as if you pay your bills on time or have filed bankruptcy – to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 14 U.S.C. 1681-1681 u et seq., at the Federal Trade Commission’s web site (http://www.ftc.gov) The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a stated attorney general to learn these rights.
• You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you – such as denying an application for credit, insurance, or employment – must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.
• You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You are also entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.
• You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its finding to the CRA. (The source must also advise national CRAs – to which it has provided the data – of any error). The CRA must give you a written report of the investigation, and a copy of the report, if the investigation results in any change. If the CRA’s investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is altered or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.
• Inaccurate information must be corrected or deleted. . A CRA must remove or correct inaccurate information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated or cannot be verified. If your dispute results in any change in your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it ahs reinserted the item. The notice must include the name, address and phone number of the information source.
• You can dispute inaccurate information items with the source of the information. If you tell anyone – such as a creditor who reports to a CRA – that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you’ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.
• Outdated information may not be reported. . In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies.
• Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA – usually to consider an application with a creditor, insurer, employer, landlord, or other business.
• Your consent is required for reports that are provided to employers, or that contain medical information. A CRA may not give out information about your to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission.
• You can choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending your unsolicited offers of credit or insurance. Such offers must include a toll free number for you to call if you want your name and address excluded from future lists. If you call, you must be kept off the lists for two years. If you request, complete and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.
• You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violated the FCRA, you may sue them in state or federal court.