Low-Income Housing Assistance Screening
Full Name
Current Address
City
State
ZIP Code
Household Size
Monthly Household Income ($)
Employment Status
Employed Full-Time
Employed Part-Time
Unemployed
Retired
Student
Other
Current Housing Status
Renting
Homeless
Own Home
Staying with Others
Other
Type of Assistance Needed
Rental Assistance
Emergency Housing
Utility Assistance
Deposit Assistance
Other