Application for 4th Street Housing
Please fill out, print, and sign the form then deliver it to Kirstin Schelling, HUD Coordinator.

GENERAL INFORMATION  

Date of Referral  ,
CMHC Office    Referral Person 

Last Name  First Name Middle Initial

ADDRESS:     Number Street   Apt.#
                  City     ZIP  
                    County  

Telephone: (Home) -        Other Contact -

DOB (Month Day, Year)  , Social Security Number --

Preference:

A. Homeless:  On the street or residing in a nighttime shelter
B. Dependent Housing: 

1. Transitional Housing (time limited) 5. Hospital
2. Nursing Home6. Living with friends or relatives
3. Adult that needs emancipation7. Inappropriate (substandard, volatile)
4. Boarding Home 

C. Rent Burden:  1. 80-100%          2. 50-80%

INCOME: List all income before any deductions

Amount

Period

Source

$

$

$

$

Qualifications:

1. Needs more intense monitoring
2. Must be 18 years of age
3. Carry a primary mental health diagnosis
4. Will not be considered for housing if primary diagnosis is drug or alcohol related. Needs to be in remission at least 2 years.
5. IQ at or above 60
6. Have no incontinence issues (bowel or bladder) unless resident is capable of self-care
7. Have no communicable diseases unless the resident is receiving medical or drug treatment
8. Have no reported violent behavior
9. No felony convictions in the past seven (7) years
10. Voluntary admittance, except on a case by case review
11. Must be ambulatory
12. Must meet section 8 income requirements

NAME OF HEAD OF HOUSEHOLD:

Signature: ______________________________________________ Date: _____________________