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US Navy Paints Elderly Housing
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Date
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How did your household become homeless?
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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
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Other Contact Number
Household Size
*
Thank you for your application! For more information, please call (671) 635-1422.
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
No
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
No
If Yes, have you been approved for Section 8?
Yes
No
How long has your household been homeless (days,months, or years)?
*
ALL APPLICANTS: Any Adults in the household currently working?
*
Yes
No
ALL APPLICANTS: Any adults in the household looking for work?
*
Yes
No
Applicant's Full Name & Today's Date
*
Applicant Full Name
*
ALL APPLICANTS: Have you applied for Section 8?
*
Yes
No
If you chose Utility Disconnection, please indicate the Utility Reimbursement Amount below
Where are you currently staying?
*
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