SPANISH Housing Intake Application

Please list your last 3 years of housing history.
Do you need help with listing out your housing history?

No, I've got this.Yes, please contact me.
Move in date:*

MonthDayYear
Date
Move out date:*

MonthDayYear
Date
Address:*
Type of housing*
Owner or lease holder:*
More to enter?*

NoYes
Move in date:*

MonthDayYear
Date
Move out date:*

MonthDayYear
Date
Address:*
Type of housing*
Owner or lease holder:*
More to enter?*

NoYes
Move in date:*

MonthDayYear
Date
Move out date:*

MonthDayYear
Date
Address:*
Type of housing*
Owner or lease holder:*
More to enter?*

NoYes
Move in date:*

MonthDayYear
Date
Move out date:*

MonthDayYear
Date
Address:*
Type of housing*
Owner or lease holder:*

By signing this form, I am stating that the information provided is true to the best of my knowledge, and I understand that by giving false information that I could be prosecuted for fraud.

I understand this is an application for assistance and not a guarantee of assistance.

The information provided will be used to determine program eligibility based upon guidelines set by the programs. I will work with MAHUBE-OTWA if any information is missing. I understand that information must be turned in within 2 weeks of being requested or my application could be denied.

I understand that financial assistance cannot be paid to family members or to me individually, only to a third-party vendor such as my landlord.

If I do not cooperate with MAHUBE-OTWA my application/assistance could be denied or ended.

I agree to a follow-up survey.

If I am assigned a family coach, I agree to work towards a permanent housing plan which means a minimum of once-a-month face-to-face meetings. The family coach can assist with goal setting, budgeting, advocating for my household, resources and referrals to other agencies and other activities related to housing stability.

I understand that assistance is to help me become self-sufficient with my housing.

I understand that if I do not cooperate with my family coach; that termination of housing assistance could happen.

I am agreeing to being added to coordinated entry in the Minnesota State Homeless Information Management System and a copy of this application serves as my receipt.
Signature*

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Today's Date

MonthDayYear
Typed name

First Last
Do you have an eviction or late payment notice from your landlord? Upload it here!

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Upload your proof of income here!

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Thank you for competing this Housing Intake Form. Our team will review your submission be in touch with you if additional information is needed or once funding is available. Upon submission you will be directed to sign and date two additional documents.

1) The first gives us permission to enter your information into the state housing data base HMIS.

2) The second gives us permission to use your information internally to see if you are eligible for other programs or opportunities that MAHUBE-OTWA offers.
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