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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