PH Application

A transitional, faith-based, supportive housing program for single women with children.

Downloadable PDF Form

Today’s Date:

Are you homeless?(Required)

Yes

Have you ever applied for this program before?

Yes

Please summarize your current living situation.(Required)

PERSONAL INFORMATION

First Name(Required)

Middle Name

Last Name(Required)

Suffix

Please let us know who referred you or how you heard about Project Hope:

Ever received services under different name?

Yes

If yes, then provide:

First name

Middle name

Last name

Suffix

Marital Status

Date of Birth

U. S. Citizen

Yes

Alien Status

(You must have a valid Florida Driver’s License or State ID to be considered for the PH program)

Current Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone(Required)

Email(Required)

Race(Please pick at least one racial designation, choose all that apply):

American Indian or Alaska Native

Black or African American

White

Asian

Native Hawaiian or Other Pacific Islander

Hispanic/Latino

Other

Military Status:

Yes

servedin U.S. Military (veteran):

Before 2002

Yes

Will you need any accommodations to participate in this program?

Yes

Please explain your condition and describe what accommodations you will need

CURRENT HOMELESS STATUS:

Where did you stay last night (choose one):

If you are currently housed, are you being evicted within 30 days?

Yes

Where did you stay before last night?(

Total number of times homeless (including this time - choose one):

Number of times homeless in the past five years (choose one):

How long have you been homeless this time?(choose one):

Less than 1 month

1 to 3 months

4 to 6 months

7 to 11 months

12 mos. to 2 years

3 to 5 years

6 to 10 years

More than 10 years

Reasons or contributing factors to homeless situation (s)(may check more than one):

Tell us about your last permanent address(where you last lived for 90 days or more):

Last Permanent Address

Last Permanent City:

State/Province

Last Permanent Zip Code

Dates resided from

This address is:

Within city limits of Ocala

Outside of city limits, but within Marion County

Other County

Please list all states that you have lived in since the age of 18:

State

City

County

Dates lived there

State

City

County

Dates lived there

State

City

County

Dates lived there

State

City

County

Dates lived there

EMPLOYMENT:

Currently Employed:

Yes

How Many Hours Worked Last Week

Type of Work:

Full-time

Part time

Permanent

Temporary

Seasonal

other

Contract

If not employed, are you looking for work:

Yes

If not employed, how long did you work on last job:

From

Type of work

If not employed explain why

Income from work & other sources:

Received Income From Work Last Month

Yes

Income from Employment in Dollars. $

Income received from other sources

Yes

Unemployment: $

Retirement from Soc Security: $

Supplemental Security Income. $

Veteran’s Pension: $

Veteran’s Disability Payment: $

Child Support: $

Private Disability Insurance: $

Alimony/Other Spousal Supp: $

Worker’s Compensation: $

Aid to the Needy and Disabled. $

Temp Assist for Needy Families: $

Old Age Pension (OAP). $

General Assistance: $

Other Sources:

Non-Cash Benefits

Food Stamps

Eligible

Application Submitted

Currently Receiving

Past Recipient

Medicaid Health Insurance

Eligible

Application Submitted

Currently Receiving

Past Recipient

Medicare Health Insurance

Eligible

Application Submitted

Currently Receiving

Past Recipient

Florida Kid Care

Eligible

Application Submitted

Currently Receiving

Past Recipient

Women Infants Children (WIC)

Eligible

Application Submitted

Currently Receiving

Past Recipient

Veteran’s VA Medical Services

Eligible

Application Submitted

Currently Receiving

Past Recipient

CDS - Child Care Services

Eligible

Application Submitted

Currently Receiving

Past Recipient

Rental Assistance, Section 8, Housing Vouchers

Eligible

Application Submitted

Currently Receiving

Past Recipient

Housing assistance through any other agency

Other benefit sources

EDUCATION:

Are you in school now:

Yes

Working on a degree/certification:

Yes

Do you have a vocational or apprenticeship certificate

Yes

Highest level of education completed (choose one):

Received Degrees (choose all that apply):

Technical Degree or Certificate

Masters Degree

Doctoral, all but dissertation

Associates Degree

Doctoral Degree

Other Graduate Degree

Bachelor’s Degree

Post-Doctoral Work

CHILDREN (for minors up to age 17):

Total number of children:

Last Name

First Name

Sex

DOB

Race

Name of School/Daycare

SSN

Last Name

First Name

Sex

DOB

Race

Name of School/Daycare

SSN

Last Name

First Name

Sex

DOB

Race

Name of School/Daycare

SSN

If child(ren) is/arebetween ages 4-17and not in school explain why(may check more than one):

None

Physical exam requirements

Lack of available preschool programs

Residency requirements

Immunization requirements

Legal guardianship requirements

Birth certificates

Transportation

Availability of school records

If younger than age 4, why not in daycare (may check more than one):

Expensive

Not wanting to enroll

Lack of available/open programs

Do not qualify for CDS

Immunization requirements

Physical Exam requirements

Availability of records

Transportation

Legal guardianship requirements

Who has legal custody of the child(ren)?

Where are they living?:

Do you or the other parent have visitation rights?

Yes

If yes, how often & where does this occur?

Is there a safety concern? If yes, please explain.

Have you ever been investigated for child abuse and/or neglect:

Yes

If yes, list dates

involved:

If yes, explain incident:

DCF Caseworker’s Name:

Phone

City/State/County:

Dates of involvement:

What was the outcome?

DOMESTIC VIOLENCE:

Experienced Abuse:

Current

In the Past

If Current or Past, How Recent:

Immediately prior to contact

24-48 hours ago

Last week

Last month

Don’t know

3 – 6 months

6 –12 months

More than 1 yr

Don’t know

Is there a current safety concern:

Yes

HEALTH INFORMATION:

General Health (choose one):

Excellent

Very Good

Good

Fair

Poor

Currently Pregnant:

Yes

Don’t Know

Not Applicable

If yes, what is the due date:

(MM/DD/YYYY)

DRUGS:

Have you ever used drugs?

Yes

If yes, when and what:

When was the last time you used drugs?

Have you ever been in a drug treatment program?

Yes

If yes, dates, city and state, name of treatment facility:

Have you ever been arrested for any drug related offenses?

Yes

If yes, dates, city and state, offense:

SUBSTANCE USE:

a. When was the last time you had something alcoholic to drink?

b. How much do you drink at one time?

c. How many times did you drink last month?

d. Is there a history of alcoholism in your family?

e. Has your drinking caused any problems for you?

Yes

Please explain:

Have you ever been arrested for any alcohol related driving offenses?

Yes

Please explain

Have you ever been in an alcohol treatment program?

Yes

If yes, when and where:

CRIMINAL BACKGROUND:

Have you ever been arrested or ever been charged with a Felony?

Yes

If yes, list dates, city, county, state, and explain

Are you currently involved in any court/legal proceedings?

Yes

If yes, list dates, city, county, state, and explain:

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:

1. Educational Goals:

2. Career Goals:

3. Life Goals:

EMERGENCY CONTACT:

Name:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Relationship

REFERENCES

(List people, unrelated to you, who we can contact for references.)

Personal/Professional Reference:

Full Name:

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship

How long have you known

Personal/Professional Reference:

Full Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship:

How long have you known:

Personal/Professional Reference:

Full Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship

How long have you known

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.

Applicant Signature

Date

Check ALL that Apply

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.

Applicant Signature

Date

Please CompleteALL12pages to include Fair Credit Reporting Act & CMIS Reprogram agreement. Incomplete or illegible applications will be returned. Return completed application to: Project Hope * 830 NE 28th St. #201 * Ocala, FL 34470

All applicants are to be assured of confidential treatment of personal information to the extent possible. Project Hope shall obtain written permission from the program participant in agreement of information to be releases, unless such program agreement is otherwise authorized by law.

Address & Employment History

Name of Applicant

Intake Appointment

List the places you have resided in the past 5 years.

1. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates resided

from

Within city limits of Ocala, Florida

Yes

2. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates resided

From

Within city limits of Ocala, Florida

Yes

3. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates resided

From

4. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates resided

From

5. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates resided

From

6. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates resided

From

7. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates resided

From

List the places you have been employed in the past 5 years.

Present Employer:

Name of Company:

Name of Supervisor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Assigned Tasks

Start Date

Assigned Days & Hours:

Pay Rate:

1. Previous Employer

Name of Company:

Name of Supervisor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Assigned Tasks

Start Date

Reason for Leaving:

2. Previous Employer:

Name of Company:

Name of Supervisor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Assigned Tasks

Start Date

End Date

Reason for Leaving:

3. Previous Employer:

Name of Company:

Name of Supervisor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Assigned Tasks

Start Date

End Date

Reason for Leaving:

4. Previous Employer:

Name of Company:

Name of Supervisor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Assigned Tasks

Start Date

End Date

Reason for Leaving:

5. Previous Employer:

Name of Company:

Name of Supervisor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Assigned Tasks

Start Date

End Date

Reason for Leaving:

Project Hope of Marion County

Consent to Program Agreement Information

If you consent, we have the ability to share your information with our collaborating entities to be used for intake assessment. You can choose to share all or part of the information that you have submitted including basic demographic information, residential, employment skills/income, military/legal, service needs, goals, and outcomes. This cannot take place unless you provide written consent by signing and dating this Consent to Reprogram Agreement Information. No medical, mental health or substance use history will be shared unless you provide express written consent. Your information and information contained on the application about other residents will be shared for a period of no more than 4 years from today’s date.

authorize Project Hope to disclose to appropriate entities any information regarding my general condition, past and present, and/or information about other family members or other residents contained in the application concerning services provided to and/or required by me and others I have listed on the application. This consent may be revoked by me or any other family member or resident, at any time except to the extent that action has been taken in reliance thereon. This consent unless expressly revoked earlier will expire four years from the date indicated below. I declare that the information I give is true and correct to the best of my knowledge.

Signature(Required)

Date

Print Name

Witnessed by

Date

Print Name

FAIR CREDIT REPORTING ACT

DISCLOSURE AND AUTHORIZATION

Disclosure: In order to evaluate your application for Project Hope’s Transitional Housing Program or, if accepted, to assist management with decisions, Project Hope may obtain consumer reports, investigate consumer reports and criminal history records check regarding you. These reports are any information from a consumer reporting agency bearing upon your credit history, character, reputation, personal characteristics, medical information, or mode of living which is used or collected for the purpose of informing any decision regarding your prospective or actual program relationship.

You have certain rights regarding these reports and their use as defined under the Fair Credit Reporting Act and as summarized in “A Summary of Your Rights under the Fair Credit Reporting Act” which has been provided to you.

Authorization: I voluntarily authorize Project Hope to obtain consumer reports, investigative consumer reports and criminal history records check about me in order to make informed decisions regarding my proposed or actual program relationship with Project Hope. The information obtained may include medical information. I acknowledge that I have rights under the Fair Credit Reporting Act including those discussed in “A Summary of Your Rights under the Fair Credit Reporting Act” which I have received and reviewed.

Printed Name

Date

Social Security Number

Date of Birth

Gender

Male

Female

Driver’s License #

State

Maiden Name/Alias

Other Aliases

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.