HomeShare Application

I am interested as (select one)(Required)

Applicant Information

Race (choose all that apply)(Required)
Ethnicity(Required)
Gender(Required)
Disabling Condition(Required)
Vaccination Status(Required)
Would you require the person you are living with to be vaccinated against COVID-19?(Required)

Co-Applicant Information

Co-Applicant Race (choose all that apply)
Co-Applicant Ethnicity
Co- applicant Gender
Co-Applicant Disabling Condition

Other Household members currently living with you

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

Employment

Type of Work

Other Employment

Type of Work
Are you able to handle your own personal care? (bathing, feeding, toileting, transferring, ambulation, taking medication, dressing, etc.)(Required)
Have you ever been convicted of a felony or misdemeanor?(Required)
Are you currently, or have you ever been on probation?(Required)
Have you ever been evicted?(Required)

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.