SL SOLUTIONS HOUSING APPLICATION

Basic Information

Full Name

Preferred Nickname

Date of Birth

Month

Day

Year

Phone Number

Email Address

Housing Situation

Current Address

City

State

Zip Code

Are you currently homeless?

Yes

No

Emergency Contacts

Name

Phone Number

Relationship

Email

Monthly Income

Total Monthly Income: $

Are you currently employed?

Full Time

Part Time

No

Housing Needs

Desired move-in date?

What type of housing are you seeking?

Do you smoke?

Yes

No

Do you have pets?

Yes

No

Support & Services

Do you currently have a case manager or social worker?

Yes

No

Eligibility Details

Veteran

Domestic Abuse Survivor

Low-income Household

Currently Home or At Risk

Assistance Services Neeed (Optional)

Employment Assistance

Counselling Services

Legal Aid

Medical & Safety Screening

Are you able to independently preform daily living activites?

Yes

No

Do you require around-the-clock care?

Yes

No

Do you have any medical conditions staff should be aware of?

Are you currently taking prescribed medications?

Yes

No

Background Information

Have you been convicted of a violent felony within the past 5 years?

Yes

No

Are you currently on probation or parole?

Yes

No

Program Agreement

I understand residents must be able to live independently.

I understand submission of this application does not guarantee placement.

I certify that the information provided is true and accurate.

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Signature

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Government ID

Please upload a valid state ID

Referral Letter or Document

Please upload any referral letters/documents you may have (optional)

Proof of Income

Please show paystub or other proof of income

Application