Name: __________________________________Date of Birth
PAH provides shelter for single women, women and families (including if significant other is male or female), single men with children. Our program requires a high level of commitment and involvement-including regular meetings with the Shelter Advocate to work on goals in hopes of securing affordable housing options. If Program expectations are met, shelter can be up to a 90 day stay. There is 10:00 PM curfew and daily chores are assigned to each room. Each Adult will need to complete a background check. Please initial if you are willing to participate in our programing: _____________
We have Shelters in Mankato and St. Peter, MN. Please indicate which ones you would like to apply to stay:
Mankato ____ St. Peter ____
Name: Date of Birth:
SSN# ________________________ Marital Status: Married ____ Single ___ Divorced ___ Widowed ___
Significant Other Name: _______________________________________ Date of Birth: ___________________
SSN# ________________________ Phone # ___________________ Email: ____________________________
Best way to get ahold of you: __________________________________________________________________
Please indicate your current residence status:______________________________________________________
Length of stay: ______________________________________________________________________________
Reason they need/want to leave current residence:
Do you have access to transportation?
Is this your first experience being homeless? ______________________________________________________
Have you been in any other shelters within the last year?_____________________________________________
Please explain your need for services from Partners for Affordable Housing-
(What do you feel contributed to your current state of homelessness?)
Are you receiving any services/help from any Agencies or Professionals, such as: County Financial Services, MVAC, Salvation Army, CADA, Child Protection, Drug Court, School District Social Workers, Catholic Charities, Mental Health Providers etc.?
Please Name them and explain: _________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
Please list the Child/Children who will be residing with you at shelter:
Name: Date of Birth:
Grade/School
Name: Date of Birth:
Grade/School
Name: Date of Birth:
Grade/School
Is any child in daycare? If So who?________________________________________
Child Care Provider: _________________________Phone: _______________
Criminal History
Conviction of a crime will NOT automatically exclude you from the program.
Adults-Do you have any current outstanding criminal justice issues? ____________________________________
Adults-Any Felonies or violent crimes within the last 3 years?
Please Explain:
Are you on probation? ______ Probation Officer Name:
Phone Number to Probation Officer Probation Ends:
Employment/Income Background
Are you currently employed? _____ Employer:
How many hours per week? _______ Hourly wage? ________ Date started?
Employment status: Permanent ______ Temporary ______ Seasonal _____
Other sources of income:
Assistance: MFIP:$ ________ DWP: $________ GA: $________ Child Support $ ________
Social Security income: $________ Retirement Pension: $ ________ Disability or Worker’s Comp? $ ________
Do you Receive SNAP benefits? _________
Health/Disability History
Do you have health insurance? _________ Do you consider yourself, or another member of the family, as having a disability? ________________
Who has this disability? please indicate the disability below:
Physical ___ Mental ___ Developmental ____ other: _________ Is the disability long term? _____________
Has this disability been diagnosed by a medical doctor/ mental health therapist? __________________
Have you been diagnosed with a Substance Use Disorder? ________________________________
What is your chemical of choice?
Have you attended treatment? _______ If so, when and where? Please indicate if inpatient or outpatient:
Are you currently in recovery? ________ How long have you been sober? ______________________________
Do you or your children use any medications including prescription and non-prescription medications, drugs or alcohol? If so, who and what are they?
Any additional health information or special accommodations for staff to be aware of:
Housing History
Last permanent address:
Length of time at that residence? _________________ Were you a Lease Holder? ______________________
Landlord’s Name and Phone Number:
Why did you leave?
Number of Evictions or Unlawful Detainers: _______________________________________________________
Reason(s) for evictions: ______________________________________________________________________
Do you have any outstanding back rent, utility bills, or any other debt that could be a barrier to securing housing?___________________________________________________________________________________
__________________________________________________________________________________________
Do you have any credit challenges? _____________________________________________________________
Have you applied for Section 8 or Public Housing? _________________________________________________
Veteran Information
Are you or an immediate family member an active or retired Veteran of the Armed Forces?
If so which branch and unit?
Years of Service? _________ Do you use VA Services?
Other Information
Any additional information you feel is important for us to know.
Are there any unsafe people in your life? Please identify them.
Emergency Contact Name: _______________________________________Relationship
Phone Number: __________________________________________
Can we contact this person if we cannot get a hold of you? ___________________________________________
I certify the information in this application is true and correct. I authorize Partners for Affordable Housing to contact the sources listed in this application for the purpose of verifying the accuracy of the information. Completion of application does not guarantee approved admission into the Program or an expectation of privacy.
Signed: Date:
(Name of Applicant)
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