Francis homes interest form

Thank you for your interest in participating in the Francis Homes housing program. Please complete the following information in full and return to bhein@shelterdevelopment.org. Application materials will be processed in the order received.

Francis Home Application

Head of Household Contact Information

First name

Last name

Phone

How many individuals are in your household?

Number

Please list all adults in the household and their ages.

Short answer

Please list any children in the household and their ages.

Short answer

Have any of your adult household members experienced the following:

(Please check all that apply.)

No previous Rental History

Insufficient Savings

Past Eviction(s)

Poor Credit

Criminal Background

Sporadic Employment

No High School Diploma/GED

Please describe your current housing situation.

Long answer

Are you currently participating in a support program (including housing, employment, or case management support?

Choose one:

Yes

If so, whom?

What agency or program?

Who is your contact?

Income Verification Section

Francis Homes Program is intended to provide short term, stabilizing housing (18-24 months) for households meeting the definition of Low, or Very Low income for La Crosse County, Wisconsin.

Please complete the following Income section and provide supporting documentation to determine program income eligibility.

Gross Monthly Income (combined for all household members):

Gross Monthly Income

Monthly Income from Employment:

Employment Income

Monthly Income from Other Sources (please identify)

Short answer

attest the information provided above is correct to the best of my knowledge.

Signature

Signature field is empty.