Eden, Inc. Housing Application Form Page 3
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7Third Project Housing Application
Type of Housing Needed/Desired – Check & Explain All That Apply
Single Home _____
Apartment _____
Condo _____
Duplex _____
Explain_________________________________________________________________
Number Of Bedrooms: One _______ Two _______ Three _______ More ______
Explain (If More Than One) ________________________________________________
Location – East _______
West _______
Any _______
If Specific, List Areas You Will Accept________________________________________
Special Accommodations Needed____________________________________________
________________________________________________________________________
Please List All Household Members (Use Back Of Page To List Additional Members)
Name__________________________________________ Relation_________________
Age _______ Income ______________ Source_________________________________
Name__________________________________________ Relation_________________
Age _______ Income ______________ Source_________________________________
Name__________________________________________ Relation_________________
Age _______ Income ______________ Source_________________________________
Income/Resources/Entitlements – Check All That Apply & Attach Documentation To
This Application. (If Pending, Indicate Date You Applied and Status)
___SSI
Amount_______________
Status___________________
___SSDI
Amount_______________
Status___________________
___Employment
Amount_______________
Status___________________
___ADC/OWF
Amount_______________
Status___________________
___GA/DA
Amount_______________
Status___________________
___Other
Amount_______________
Status___________________
Payee (If Applicable)______________________________________________________
(Name)
(Address)
(Phone)
I attest that all the information provided is correct to the best of my knowledge. Any
changes or additional data will be provided to Eden, Inc.
Applicant Signature___________________________________________ Date________
Mental Health Professional Signature______________________________ Date_______
Page 3 of 3
Updated 8/15/2006ka
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