Housing Intake Application Revised: April 3, 2026

  • Housing Intake Application

    Open to MN families, individuals and/or unaccompanied minors with a household income of less than 200% of the Federal Poverty Guidelines. Please allow us (up to) 2 weeks to review your application and follow up with you.
  • Format: (000) 000-0000.
  • Preferred contact method:

  • **If you are currently homeless, type "Homeless" in the physical address box.

  • Same Mailing Address?
  •  - -
  • US Citizen?*
  • Race (select all that apply)*
  • Ethnicity*
  • Disability Type
  • US Military or Veteran?*
  • Type of Service*
  • Have you been referred to the Homeless Veteran Registry?*
  • Exposed to or survivor of Domestic Violence?*
  • How long ago?*
  • Still Fleeing*
  • Health Insurance*
  • Pregnant?
  • Highest Level of Education Completed*
  • Currently attending school?
  • Others living in your household?*
  • Choose one:*
  •  - -
  • US Citizen?
  • Race (select all that apply)
  • Ethnicity
  • Disability Type
  • US Military or Veteran?*
  • Type of Service*
  • Have you been referred to the Homeless Veteran Registry?*
  • Exposed to or survivor of Domestic Violence?*
  • How long ago?*
  • Still Fleeing*
  • Health Insurance*
  • Pregnant?
  • Highest Level of Education Completed
  • Currently attending school?
  • More household members to enter?*
  • Choose one:*
  •  - -
  • US Citizen?
  • Race (select all that apply)
  • Ethnicity
  • Disability Type
  • US Military or Veteran?*
  • Type of Service*
  • Have you been referred to the Homeless Veteran Registry?*
  • Exposed to or survivor of Domestic Violence?*
  • How long ago?*
  • Still Fleeing*
  • Health Insurance*
  • Pregnant?
  • Highest Level of Education Completed
  • Currently attending school?
  • More household members to enter?*
  • Choose one:*
  •  - -
  • US Citizen?
  • Race (select all that apply)
  • Ethnicity
  • Disability Type
  • US Military or Veteran?*
  • Type of Service*
  • Have you been referred to the Homeless Veteran Registry?*
  • Exposed to or survivor of Domestic Violence?*
  • How long ago?*
  • Still Fleeing*
  • Health Insurance*
  • Pregnant?
  • Highest Level of Education Completed
  • Currently attending school?
  • More household members to enter?*
  • Choose one:*
  •  - -
  • US Citizen?
  • Race (select all that apply)
  • Ethnicity
  • Disability Type
  • US Military or Veteran?*
  • Type of Service*
  • Have you been referred to the Homeless Veteran Registry?*
  • Exposed to or survivor of Domestic Violence?*
  • How long ago?*
  • Still Fleeing*
  • Health Insurance*
  • Pregnant?
  • Highest Level of Education Completed
  • Currently attending school?
  • More household members to enter?*
  • Choose one:*
  •  - -
  • US Citizen?
  • Race (select all that apply)
  • Ethnicity
  • Disability Type
  • US Military or Veteran?*
  • Type of Service*
  • Have you been referred to the Homeless Veteran Registry?*
  • Exposed to or survivor of Domestic Violence?*
  • How long ago?*
  • Still Fleeing*
  • Health Insurance*
  • Pregnant?
  • Highest Level of Education Completed
  • Currently attending school?
  • More household members to enter?*
  • Choose one:*
  •  - -
  • US Citizen?
  • Race (select all that apply)
  • Ethnicity
  • Disability Type
  • US Military or Veteran?*
  • Type of Service*
  • Have you been referred to the Homeless Veteran Registry?*
  • Exposed to or survivor of Domestic Violence?*
  • How long ago?*
  • Still Fleeing*
  • Health Insurance*
  • Pregnant?
  • Highest Level of Education Completed
  • Currently attending school?
  • Does anyone in your household have an income?*
  • Does anyone in your household receive Non-Cash Benefits? (SNAP, WIC, TANF, LIHEAP, Housing Choice Voucher, Public Housing, Permanent Supportive Housing, HUD-VASH, Childcare Voucher, Affordable Care Act Subsidy)*
  • List the non-cash benefits you receive currently:*
  • Type of assistance needed (check all that apply and list amount needed in other)*
  • Do you have transportation or a means to get to appointments?*
  • Where did you stay last night? (check one)*
  • Do you receive a housing voucher or subsidy to help you pay rent each month now?*
  • How long can you stay in your current housing situation? Add specific date if you select other.*
  • What are the reasons you need to leave your current housing situation?*
  • Is emergency shelter needed?*
  • Do you anticipate your household size to change in the near future?*
  • Have you been homeless before? (Doubled up in someone else's home, living in a camper/car, staying in a motel, shelter, tent)*
  • Homeless in the past 12 months?*
  • Have you been homeless continuously for over a year?*
  • Have you had four or more episodes of homelessness in the past three years? (Doubled up in a home or a place not fit for habitation like a car or garage)*
  • Have you stayed in a shelter or house program before?*
  • Have any of these factors created a barrier for you in finding or keeping housing? (check all that apply)*
  • In the last 2 weeks, have you been able to make scheduled health and emotional appointments?*

  • Please list your last 3 years of housing history.  

  • Do you need help with listing out your housing history?
  •  - -
  •  - -
  • More to enter?*
  •  - -
  •  - -
  • More to enter?*
  •  - -
  •  - -
  • More to enter?*
  •  - -
  •  - -

  • 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.

  • Clear
  •  - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 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.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: