Chelan-Douglas Homelessness Prevention Waitlist Application

ඔබගේ බ්‍රවුසරයේ ජාවාස්ක්‍රිප්ට් සබල කර නැත, එම නිසා මෙම ගොනුව විවෘත කළ නොහැක. සබල කර නැවත පූරණය කරන්න.

The Chelan-Douglas Homelessness Prevention Program is not currently accepting new clients. Please fill out the application below to be screened. There are eligibility requirements for the program. Filling out this application DOES NOT GUARANTEE THAT YOU WILL BE ADDED TO THE WAITLIST OR RECEIVE SERVICES. Since the program is not accepting new clients, and it is not certain when the program will accept new clients, the Coordinated Entry Specialists will ONLY contact you via email. They will let you know via email if you met criteria to be added to the waitlist. Thanks for your understanding.

ඔබේ ප්‍රගතිය සුරැකීමට Google වෙත පුරන්න. තව දැන ගන්න

What is your first and last name? *

Phone number

Email Address *

What is the amount that you currently owe in rent? *

What caused your situation? *

After receiving assistance, do you believe that you would be able to sustain rent moving forward on your own? *

Yes

Unsure

If not, or unsure, could you please explain why?

Have you worked with your landlord to set up a payment plan, utilized mediation services, or have tried to resolve this issue by any other means? *

Payment Plan with Landlord

Mediation Services

Received Financial Assistance but still owe

Other

අත්‍යාවශ්‍යයි

Do any of the following situations apply to you? *

Have missed rent payment and currently owe all or part of a rent payment

Has moved because of economic reasons 2 or more times in the last 60 days

Living in a home of another because of economic hardship

Has been notified that you need to leave your current housing situation in the next 21 days

Living in a hotel or motel and the cost is NOT paid for by an organization

Live in single room occupancy where two or more people live

Live in a larger housing unit where there resides more than 1 and 1/2 persons per room

Exiting a publicly funded institution or system of care

අත්‍යාවශ්‍යයි

Do you have a legal eviction noticed? Note: Eviction notice is a legal document in which you have a court hearing. This is NOT the same as a pay or vacate. If you have a pay or vacate notice, please indicate that below. *

Yes

No - I don't have a notice, I am just late and/or behind on rent

I have a pay or vacate notice

Do you have income? *

Yes, I am employed, receive benefits, or have another source of income

No I do not have any income at all

If you answered, "Yes, I am employed, receive benefits, or have another source of income" please indicate what benefits below. If you answered no, please select no again.

No - I do not have any source of income

Earned income

Unemployment Insurance

Supplemental Security Income (SSI)

Social Security Disability Insurance (SSDI)

VA Service- Connected Disability Compensation

VA Non-service Connected Disability Pension

Private Disability Insurance

Worker's Compensation

TANF

General Assistance (GA)

Retirement Income from Social Security

Pension or Retirement Income from a Former Job

Child Support

Alimony and Other Spousal Support

Other Income Sources

Approximately how much is your monthly income? If you do not receive income, please put zero. *

Including yourself, how many people live in your household? *

How many bedrooms is your current unit? *

Studio

1 Bedroom

2 Bedroom

3 Bedroom

4 bedroom

5 or more bedrooms

Do any of these situations apply to you? *

Experienced homelessness in the past 5 years

Owe more than three months of rental arrears, including this months rent

History of housing disruption due to discrimination of any kind

Lack of resources from friends or family

අත්‍යාවශ්‍යයි

Have you or a member of your household currently have any of the following severe or disabling conditions *

Physical

Developmental

Mental

Emotional - includes PTSD or a Traumatic Brain Injury (TBI)

අත්‍යාවශ්‍යයි

Are you between the ages of 18-24? *

Yes

If you answered yes to are you 18-24, do any of these situations apply to you? *

Are you currently pregnant or parenting?

Are you a recipient of foster care, adoption, mental health care, drug or alcohol treatment

Have you been involved with the court system?

No - none of these apply to me

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