Home for Awhile Application - Cornerstone Church

Your name *

Email address *

Phone number *

What is your current situation? What factors have led to your need to apply for temporary housing through Home for Awhile? *

Have you reached out to Story County Services? (515) 663-2930 *

Yes

Household members

What is the name of each person who will be living in household? (including yourself) please provide name, age, and gender.

Where do you currently live? City, State. *

Name of current or most recent landlord?

Please include address and phone number.

Current church affiliation?

What is the name and phone number of a friend or alternative way to contact you? *

Name one person as a personal reference. Someone who knows you and can speak to your character? *

Please include address and phone number.

Have you completed high school or have your GED? *

How many years of college have you completed?

Have you completed any special certifications or licenses? If so, which ones? *

Are you or anyone else in your household employed? *

List income from all sources. (i.e. primary, 2nd or 3rd jobs, FIP, Food Stamps, SSI, Disability, etc.) *

List any medical or counseling services you or any current household members receive?

Do you have a driver's license? *

Yes

Do you have a car? *

Yes

Did you serve in the military?

Yes

What past due bills or unpaid debt do you have?

Past rent

Past Utilities

Cell phone

Medical

Credit Cards

Child support

Tickets

Other

Is anyone related to the household currently in prison/jail? Please explain. *

Is anyone in the household currently on parole or probation? Please explain. *

Are you willing to communicate weekly and meet occasionally with an HFA Ally? *

Yes

Do you agree to follow HFA Rules? *

Yes

1. I will maintain full-time employment or, if I do not have a job, each weekday I will actively seek full-time employment.

2. I will talk with my ally at least once a week to establish personal goals and work together toward reaching those goals.

3. I will continue to expand my “community” by attending a local church of my choice whenever possible.

4. I will pay a $50 deposit for the first month of my participation in the program (to be returned if the apartment is left in good, clean condition) and $200/month for the second and third months.

5. I will be quiet and friendly towards my neighbors.

6. I will actively work toward securing a new housing situation and leave the HFA housing at or before three months.

7. I will immediately report any problems or repairs needed with the residence to the HFA management or my family ally.

8. Only the persons listed on my application will spend the night in the residence.

9. I will NOT SMOKE inside or near the entrance to the residence.

10. I will keep the residence clean, safe, neat and well-maintained.

11. I will keep NO PETS either inside or outside of the residence.

12. I will notify my ally if I plan to not occupy the apartment for more than seven consecutive days.

13. I will surrender and lay no claim to any personal property left on the premises if I have abandoned the residence.

14. I understand that I will be dismissed from the program, and the residence will be considered abandoned, if I am not in communication with my family ally or HFA management for fourteen consecutive days.

15. I will make sure that children in my household under the age of 12 are attended by a responsible adult at all times.

16. I will make sure that my children will be respectful of my neighbors.

17. I will ensure that school-age children attend school and are supported in their classroom work.

Please print your name to verify all information is correct. *