If you are in need of housing: Are you currently living in a shelter, motel or transitional housing? [ ] Yes [ ] No If yes, name of place staying: How long have you been there? How long can you stay? Are you currently on a housing waiting list? [ ] Yes [ ] No If yes, For how long? Have you ever been evicted? [ ] Yes [ ] No If so, when and for what reason: Notes: Transportation Please check appropriate spaces: Yes No I have a valid driver’s license. If no, has your license been suspended or revoked? [ ] Yes or [ ] No If yes, when will you be eligible? Are there any requirements that you have to meet? [ ] Yes or [ ] No If yes, please explain: I have my own car. I have the use of another reliable car. I have a Dart bus stop nearby. I am currently using DART MTW System. (MTW= Moving to Work program) Have you been convicted of a moving traffic violation within the last 3 years? [ ] Yes or [ ] No How many points do you currently have? I will use the following transportation to get to and from work/schoool: My back-up transportation is: Notes: – Child Care/Elderly Care Please complete if you have a household member 18 years or younger or if your caring for an elderly person Please check appropriate spaces: Yes No I am in need of a child/elderly care provider.
If you are in need of housing: Are you currently living in a shelter, motel or transitional housing? [ ] Yes [ ] No If yes, name of place staying: How long have you been there? How long can you stay? Are you currently on a housing waiting list? [ ] Yes [ ] No If yes, For how long? Have you ever been evicted? [ ] Yes [ ] No If so, when and for what reason: Notes: Transportation Please check appropriate spaces: Yes No I have a valid driver’s license. If no, has your license been suspended or revoked? [ ] Yes or [ ] No If yes, when will you be eligible? Are there any requirements that you have to meet? [ ] Yes or [ ] No If yes, please explain: I have my own car. I have the use of another reliable car. I have a Dart bus stop nearby. I am currently using DART MTW System. (MTW= Moving to Work program) Have you been convicted of a moving traffic violation within the last 3 years? [ ] Yes or [ ] No How many points do you currently have? I will use the following transportation to get to and from work/schoool: My back-up transportation is: Notes: Child Care/Elderly Care – Please complete if you have a household member 18 years or younger or if your caring for an elderly person Please check appropriate spaces: Yes No I am in need of a child/elderly care provider.
ISS-Form.docx