Family (3+ children) History of Substance Abuse or Actively Using Drugs or Alcohol or Income Criminal History or Felony No or Poor Credit History or Chronic Mental Illness or Chronic Physical Disability (accessibility) or Chronic Homelessness to get Utilities in Head of Household’s Name Eviction History if any (when, where, why) Criminal History (dates, activity, outcome) What type of credit history do you have? ___Good ___Fair ___Poor ___No Credit History ___Don‘t Know Housing Documentation: Do you have the following housing documentation? Check all that apply Security Card picture ID Certificate of Income letter from Social Security (SSA.GOV) bank statement(s) income and asset documentation Financial Resource Assessment: Financial Resources Amount Comments Social Security Disability Income (SSDI) Office: Supplemental Security Income or SSI Office: Earned Income Unemployment Income A Veteran’s Disability Payment Private Disability Payment Worker’s Compensation Temporary Assistance for Needy Families Office: (TANF) State Disability Assistance (SDA) Retirement Income from Social Security Veteran’s Pension Pension from a former employer Employer: Trusts Other: Source of Non-Cash Benefits: Do you participate in any of the following programs? (Check all that apply) health insurance program health insurance program Administration (VA) Medical Services 8, public housing, or other rental assistance sources: __________________________________________ Debt: Origin of Debt Yes Amount Contact Information
Family (3+ children) or Income or Poor Credit History or Chronic Homelessness History of Substance Abuse or Actively Using Drugs or Alcohol Criminal History or Felony or Chronic Mental Illness or Chronic Physical Disability (accessibility) to get Utilities in Head of Household’s Name Eviction History if any (when, where, why) Criminal History (dates, activity, outcome) What type of credit history do you have? ___Good ___Fair ___Poor ___No Credit History ___Don‘t Know Housing Documentation: Do you have the following housing documentation? Check all that apply Security Card picture ID Certificate of Income letter from Social Security (SSA.GOV) bank statement(s) income and asset documentation Financial Resource Assessment: Financial Resources Amount Comments Social Security Disability Income (SSDI) Office: Supplemental Security Income or SSI Office: Earned Income Unemployment Income A Veteran’s Disability Payment Private Disability Payment Worker’s Compensation Temporary Assistance for Needy Families (TANF) Office: State Disability Assistance (SDA) Retirement Income from Social Security Veteran’s Pension Pension from a former employer Employer: Trusts Other: Source of Non-Cash Benefits: Do you participate in any of the following programs? (Check all that apply) health insurance program health insurance program Administration (VA) Medical Services 8, public housing, or other rental assistance sources: __________________________________________ Debt: Origin of Debt Yes No Amount Contact Information
housing-assessment.docx