Housing Program Application Hillcrest of Platte County Step 1 of 10 10% Applicant Full Name*FirstMiddle (required)Last Applicant Social Security*Applicant Date of Birth* Applicant Marital Status*UnmarriedMarriedSeparatedDivorcedCo-Applicant (spouse) Full NameFirstMiddle (required)Last Co-Applicant Social SecurityCo-Applicant Date of Birth Co-Applicant Marital StatusUnmarriedMarriedSeparatedDivorced Current HousingPhone Number*Email Current Address*How long have you been staying there?*Have you been asked to leave your current situation?*YesNoHow long can you stay there?*What kind of transportation do you have? Car Bus Bicycle Rely on others Have you ever lived at Hillcrest before?*YesNoWho referred you to Hillcrest?*EmploymentAre you currently working?*YesNo Employment (continued)Company Name*Employment Start Date* Pay Rate*Second Job, Company Name (if any)Second Job, Employment Start Date* Second Job, Pay Rate*Highest Grade of Education Completed*8th or less9th10th11th12thSome CollegeCollege GraduateIs your co-applicant working?YesNoCo-Applicant Company*Co-Applicant Employment Start Date* Co-Applicant Pay Rate*Co-Applicant Highest Grade of Education Completed8th or Less9th10th11th12thSome CollegeCollege GraduateMilitary ServiceHave you ever served in the military?*YesNoWhat branch?*When? (Service dates)* OccupancyList all who would be living in the apartment (including yourself):Occupant List (List All Who Will Live With You, Including Yourself):*NameAgeRelationshipSchoolRaceGender (optional) Is anyone pregnant?*YesNoWhat is the due date?* DebtList all debt:Outstanding ticket or warrant amount:*Past Rent Amount Due*Is there an eviction judgment or pending eviction?*Eviction JudgmentPending EvictionNoAmount Owed*Electric Amount Due*Electric Past Due?*YesNoGas Amount Due*Gas Past Due?*YesNoWater Amount Due*Water Past Due?*YesNoChild Support Arrears*Payday/Title Loans:*Payday/Title Loans Past Due?*YesNoOther Debt:Type of DebtAmount Monthly BillsPhone Bill*Phone Bill Past Due?*YesNoChild Support*Child Support Past Due?*YesNoCar Payment*Car Payment Past Due?*YesNoInsurance*Insurance Past Due?*YesNoStorage Facility*Storage Facility Past Due?*YesNoCredit Card*Credit Card Past Due?*YesNoMedical Co-Pays*Other Recurring Bills:Type of BillAmount IncomeIncome Currently Received from Job, Food Stamps, TANF, DFS, SSI, etc.*Source:Amount: Please explain the reason for your situation:* MedicalHave you ever been a victim of domestic violence?*YesNoWhen?*Do you or any of family members living with you receive any medical or counseling services?*YesNoMedical or Counseling Services Listing:*NameProblemMedication Do you use drugs or alcohol?*YesNoHave you ever been in drug or alcohol rehab?*YesNoWhen?*Facility Name:*Name of substance abused* LegalHave you ever been arrested?*YesNoFor what?*Did you receive a fine or sentence?*Yes, a fineYes, a sentenceNoHave you been incarcerated?*YesNoIncarceration Beginning and End Dates*Are you on probation?*YesNoName of caseworker and contact information*Are you on parole?*YesNoName of parole officer and contact information* Programs Rules The following rules of conduct shall be in effect while Participants participate in the Hillcrest Platte County program. Violation of any rule will, at the sole discretion of the Board or Staff, can be cause for immediate dismissal from the program, causing forfeiture of the apartment & supportive services. No illegal activity of any kind will be permitted. All adults in the Hillcrest program are expected to work at least 40 hours per week. All adults must attend scheduled meetings & appointments. I acknowledge that Hillcrest staff may enter my apartment to do maintenance or cleaning checks when I am not present without notification beyond immediate announcement. I acknowledge the Hillcrest staff will also perform scheduled checks of my apartment. I acknowledge that Hillcrest staff may require me to submit to random drug testing while I am participating in the transitional housing program, and that my refusal to do so will result in being asked to immediately vacate the program. Use or possession of alcohol, firearms or illegal drugs is prohibited. Curfew is 10:00 pm. This can only be waived for work schedules. Your Guests must be out of the apartments by 8:00 pm. Quiet hours are: 10:00 pm through 7:00 am. Guests must be approved through visitor applications. No overnight guests are allowed. Children under the age of 13 must be attended by an approved adult at all times. Children must be enrolled in the school district nearest Hillcrest or in the district your family originates from. It is required that children attend school every day that school is in session. No fighting of any kind will be tolerated. No animals of any kind will be allowed. Smoking is NOT permitted inside the apartments, buildings, or offices. Smoking is only permitted in outdoor designated areas. Participants must keep apartments & common areas clean and neat. A $100 program deposit will be collected at the time of move-in. This is fully refundable depending on condition of the apartment when the Participant moves out. I have read and understand that if I violate any one of these rules I may be dismissed from the Hillcrest program. I agree to hold Hillcrest Platte County and/or any other parties associated with this program in any way whatsoever, singly, or collectively, from any blame or liability for injury, misadventure, harm, loss, inconvenience, or damage suffered or sustained as a result of participation in this program or in activities associated therewith. I give permission for information to be released about me and my children, by or to any doctor, social worker, counselor, employer, landlord, shelter, agency, Rosie HMIS databases, or any other person deemed necessary by Hillcrest Platte County. I agree that my acceptance into the Hillcrest Platte County is not a rental agreement, and that this is not a landlord/tenant agreement, but an application for temporary homeless shelter & supportive services provided by the Hillcrest program. Any personal property of program Participants remaining on Hillcrest property after termination of contract for any reason will be deemed abandoned by the Participant and disposed of without further notice.MAACLink Client Consent and Release of Information MAACLink is a computer system that is used locally as a Homeless Management Information System (HMIS). Use of an HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. MAACLink is not electronically connected to HUD and is only used by authorized agencies. All MAACLink users have received confidentiality training and have signed strict agreements to protect clients’ personal information and limit its use appropriately. A Privacy Notice is available at participating agencies. It provides details on how member agencies and their employees handle client information and data sharing. I give permission to Hillcrest Platte County to collect and enter my personal and household information into the MAACLink computer system. I understand that the MAACLink system is shared with and used by authorized agencies in my community for the purposes of: 1. Assessing the needs of low-income, homeless or other people with special needs in order to give better assistance and to improve their current or future situations. 2. Improving the quality of care and service for people in need. 3. Tracking the effectiveness of community efforts to meet the needs of people who have received assistance. 4. Reporting data on an aggregate level that does not identify specific people or their personal information. I understand that: • All agencies that use MAACLink will treat my information in a professional and confidential manner. • Signing this release form does not guarantee that I will receive assistance. • My information may be shared with a third party (utility provider, landlord, etc) in order to process the service I have requested. • I have the right to a printed copy of my MAACLink file. Is all information you have provided on this form true and correct?YesNoCommentsThis field is for validation purposes and should be left unchanged.