housing form – The Centr

Personal Information
Application Copy of valid ID Proof of Income/Additional Assistance Denial Letter from Hennepin County (IF APPLICABLE) Copy of Lease/Rental Agreement (GET FROM LANDLORD) Late Payment Notice (GET FROM LANDLORD) Copy of W-9 (GET FROM LANDLORD)
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
Gender you Identify as
- MALE
- FEMALE
- NON-BINARY
- PREFER NOT TO ANSWER
Race/Ethnicity
Date of birth
MM slash DD slash YYYY
How many people in your household who are:

Children (0-18)
How many people in your household who are:

Adults (19-64)
How many people in your household who are:

Seniors (65+)
Referred by:
- LUTHERAN SOCIAL SERVICES
- URBAN HOMEWORKS
- AL-MAA'UNN
Apply For:
- Rent
- Utilities
- Internet
- All

CONSENT
By submitting this form I/We hereby certify that all of the information I/We have provided on this application is accurate to the best of my knowledge. I understand that in order to receive assistance I must be approved by Al-Maa'unn and my landlord must be willing to participate. I understand that Al-Maa'unn has the right to deny assistance if these parameters are not met.
Date
MM slash DD slash YYYY
Signature

Personal Information