Na Fan Safo Online Application

Catholic Social Service

Date *

How did your household become homeless? *

Does your household meet ONE of the following housing situations? Check the box that best applies to your situation. Economic Hardship means the household experienced a recent and significant loss of income. Situations may include employment termination, loss of income, reduction of hours, leave without pay, medical expenses, funeral expenses (immediate family members), work furlough/suspension, etc. *

My household was evicted from a housing unit (home foreclosure/rental unit) due to economic hardship.

My household will be evicted in 14 days from our current housing unit.

My household is participating in a federally-funded housing program (VASH, Public Housing, Section 8, etc.) and facing eviction due to (IF YOU CHOOSE THIS OPTION, PLEASE MARK ONE OF THE BOXES BELOW):

Utility Disconnection

Rental Arrears

My household is currently homeless.

Ethnicity *

Other Contact Number

Household Size *

ALL APPLICANTS: Are you fleeing or attempting to flee domestic violence, dating violence, sexual assault, stalking, or other dangerous or life threatening conditions related to violence? *

Yes

Mailing Address *

Please fill out the intake form below:

Na Fan Safo

Intake Application

If you have utility and/or rental arrears, Please indicate the amount below.

Best Contact Number *

If YES, How many adults in the household are currently working?

Email Address

I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT ALL INFORMATION PROVIDED IS COMPLETE AND CORRECT. I UNDERSTAND AND ACKNOWLEDGE THAT MAKING FALSE STATEMENTS IS A CRIME UNDER FEDERAL AND GUAM LAW. *

Yes

If Yes, have you been approved for Section 8?

Yes

How long has your household been homeless (days,months, or years)? *

ALL APPLICANTS: Any Adults in the household currently working? *

Yes

ALL APPLICANTS: Any adults in the household looking for work? *

Yes

Applicant's Full Name & Today's Date *

Applicant Full Name *

ALL APPLICANTS: Have you applied for Section 8? *

Yes

If you chose Utility Disconnection, please indicate the Utility Reimbursement Amount below

Where are you currently staying? *