Wayside Supportive Housing: Single Head of Household Application

Application for Residency

At Wayside Supportive Housing: 1341 and 1349 Jersey Avenue South, Saint Louis Park, MN Note: Please make sure that this form is filled out completely. If any questions do not apply to you, please indicate by writing “N/A” or “None” in the available space.

Head of Household (this is you) Personal Information

Your Name(Required)
Select date MM slash DD slash YYYY
Address(Required)

Contact Persons: List the name, address and phone numbers for two friends or relatives who generally know how to contact you should staff not be able to reach you at the number you provide above.

Contact #1(Required)
Name
Street Address
City
State
Zip
Phone
 
Contact #2(Required)
Name
Street Address
City
State
Zip
Phone
 

Recovery History:

Please enter a number greater than or equal to 1.
Describe the organizations and persons significant in your recovery. Include the name, address and phone number of any primary treatment facility, extended care facility or organization, the dates you were involved with each, and the names and phone numbers of your counselors or sponsors. (To add another row for an additional organization, click the + symbol at the end of the row.(Required)
Organization Name
Dates
Counselor Name
Phone Number
 

Personal Goals:

Housing Status:

Housing Composition: List yourself as the first member of your household. Add another row by clicking the + symbol at the end of the row. Add each member of the household who will be living in the assigned unit. Be sure to fill in all information for each member of the household.

Add all Household Members below (including yourself). Click the + symbol to add another member.(Required)
Last Name
First Name
Middle Initial
Relationship
Age
Date of Birth
Social Security Number
Sex M/F
 

Household Income

For each type of income (MFIP, SSI, Earned Income, Child Support, etc.) that your household receives, list the source and the amount of that income that can be expected during the next twelve months. To add another row, click the + symbol.(Required)
Family Member Name
Source/Type of Income
Amount Expected during next 12 months
 

General

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