Name (Last, First): # People in Household: Yes No Do you reside in Austin or Travis County? Age: Date of Birth: Last 4 digits of SSN: Primary Preferred Language: Secondary Phone: Where do you currently reside? Referred By: Referring Agency: $ $ What was your income in the last 30 days? x 12 months = Annual Income of Yes No Is client’s annual income lower than $15,850? (or below the Extremely Low Limits listed below) 1 person 2 persons 3 persons 4 persons 5 persons 6 persons 7 persons 2014 Extremely Low (30%) Income Limits $15,850 $18,100 $20,350 $22,600 $24,450 $26,250 $28,050 / Are you currently receiving any subsidized rent or rental assistance? Please include agencies and What do you specifically need assistance with? Rental App Fee Security Deposit Last Month’s Rent Utility Deposit Utility Payment(s) $ $ $ $ $ Eviction Fines Monthly Rent Moving Costs Utility Debt Other Arrears $ $ $ $ $ Yes No Pending Approval Have you located housing? to IF YES: What are the dates of your lease agreement? $ What is the cost of your monthly rent? How many bedrooms? AND
Name (Last, First): # People in Household: Do you reside in Austin or Travis County? Yes No Age: Date of Birth: Last 4 digits of SSN: Primary Preferred Language: Secondary Phone: Where do you currently reside? Referred By: Referring Agency: What was your income in the last 30 days? $ x 12 months = Annual Income of $ Is client’s annual income lower than $15,850? (or below the Extremely Low Limits listed below) Yes No 2014 Extremely Low (30%) Income Limits 1 person $15,850 2 persons $18,100 3 persons $20,350 4 persons $22,600 5 persons $24,450 6 persons $26,250 7 persons $28,050 / Are you currently receiving any subsidized rent or rental assistance? Please include agencies and What do you specifically need assistance with? Rental App Fee Security Deposit Last Month’s Rent Utility Deposit Utility Payment(s) $ $ $ $ $ Eviction Fines Monthly Rent Moving Costs Utility Debt Other Arrears $ $ $ $ $ Have you located housing? Yes No Pending Approval IF YES: What are the dates of your lease agreement? to What is the cost of your monthly rent? $ How many bedrooms? AND
RRH%20HHSP%20Application%20Form%202015.docx