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Application for assistance

Please use this application to apply for any type of aid. You must review the program guidelines before applying.
Although not all fields will apply to each applicant, please fill out this form in its entirety to the best of your ability.
**Due to the increasing demand for rental assistance due to COVID-19,
no further applications for financial assistance are currently being accepted.

* Indicates required field

Name *

First

Last

M.I *

Social Security Number *

Age *

Sex *

Male Female Other

DATE OF BIRTH (mm/dd/yyyy) *

CURRENT ADDRESS *

Line 1

Line 2

City

State

Zip Code

Country

Current/Most Recent Employer *

Title *

Start: *

End: *

Work Phone *

Home/Cell Phone *

Email *

EMPLOYER ADDRESS *

Highest level of education: *

Degrees/Certificates: *

Are you a veteran or member of the U.S. Armed Forces? *

Yes No

Do you suffer from post-traumatic stress syndrome (PTSD)? *

Yes No

Do you have a developmental or physical disability? *

Yes No

If yes, please describe: *

Have you ever been arrested? *

Yes No

If yes, were you released from jail/prison within the past 90 days? *

Yes No

Do you possess a criminal record? *

Yes No

If yes, for what offense(s)? *

Household Information

**Recent copies of all household income must accompany this application in order to be considered for Rental Assistance.

Has your household income been affected by COVID-19? If so, how? *

Have you recently applied for unemployment? *

Yes No

If so, have you been approved? *

Yes No

Other *

Please include each source of income per month & specify total amount received after taxes & deductions. May include, but not limited to child support, paycheck, cash aid, alimony, housing voucher, or other cash received for all adults living in the household
age 18+ :

Source & Amount of Income *

Including yourself, how many adults, children & pets are there in your family unit, who slept in the same location with you last night?

No. of adults (25+) *

No. of adults (18-24) *

No of children (17 & under) *

No. of Pets *

Please list the names of all persons living with you, their relationship to you, & their ages: *

Are you currently homeless [living in an otherwise uninhabitable place such as a park, car, abandoned building, tent, etc.]? *

Yes No

If yes, please answer the following four questions.

If so, why did you become homeless? (Select one or more reasons.) *

Other (please specify): *

What is the longest time that you have been continuously homeless? *

Less than 12 months More than 12 months Not Applicable

In total, how long have you been homeless in the past 3 years? *

Less than 12 months More than 12 months Not Applicable

Requested Aid Information

What type of aid are you requesting from Legacy Shelters (check all that apply)? *

Rental assistance: Amount $ *

Community closet (i.e. food &/or other necessities, please specify): *

Other (please specify): *

References:

Name: *

Contact information: *

Name: *

Contact information: *

Name: *

Contact information: *

Please check this box if you are filling out this form for someone other than yourself.

Name *

Date *

Release of Information

I certify that the above information is true. I authorize Legacy Shelters to verify any of the information I have voluntarily provided (signature or full name required):

Typed Signature Required *

Date *

Accompanying Documents *

Max file size: 20MB

Accompanying Documents *

Max file size: 20MB

Accompanying Documents *

Max file size: 20MB

Submit

legacy_shelters_-_cr-0021949.pdf
File Size:	619 kb
File Type:	pdf

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​Application for assistance

Household Information

Requested Aid Information

References:

Release of Information

Application for assistance