USHS Family Indication of Interest Form by ILvxNEEK

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									                                             USHS Family Indication of Interest Form

Section I: Head of Household Information

       HoH Last Name:                                                       Suffix:
       HoH First Name:                                                      Alias:
         Middle Initial:


                                                                                                      Single
Social Security                                                             Marital Status:
Date of Birth:                                                                                        Married


Client Contact Information
                   Street Address:
                              City:                                                                     State:
                         Zip Code:


Gender:          Male         Female
Race:       African America or Black        White American Indian or Alaskan Native           Asian       Pacific Islander
Ethnicity:        Hispanic           Non-Hispanic
Has head of household served on active duty in the US Military?            Yes        No
Full-Time Student:      Yes           No


Family Member

Last Name                                                                   Suffix:
First Name:                                                                 Alias:

Relationship to Head of Household:

                                                                                                      Single
Social Security                                                             Marital Status:
Date of Birth:                                                                                        Married


Gender:          Male         Female


Race:       African America or Black        White American Indian or Alaskan Native           Asian       Pacific Islander
Ethnicity:        Hispanic           Non-Hispanic
Has family member served on active duty in the US Military?                Yes        No
Full-Time Student:      Yes           No




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                                             USHS Family Indication of Interest Form

Section I: Head of Household Information

       HoH Last Name:                                                       Suffix:
       HoH First Name:                                                      Alias:
         Middle Initial:


Family Member

Last Name                                                                   Suffix:
First Name:                                                                 Alias:

Relationship to Head of Household:

                                                                                                      Single
Social Security                                                             Marital Status:
Date of Birth:                                                                                        Married


Gender:          Male         Female


Race:       African America or Black        White American Indian or Alaskan Native           Asian       Pacific Islander
Ethnicity:        Hispanic           Non-Hispanic
Has family member served on active duty in the US Military?                Yes        No
Full-Time Student:      Yes           No




Family Member

Last Name                                                                   Suffix:
First Name:                                                                 Alias:

Relationship to Head of Household:

                                                                                                      Single
Social Security                                                             Marital Status:
Date of Birth:                                                                                        Married


Gender:          Male         Female


Race:       African America or Black        White American Indian or Alaskan Native           Asian       Pacific Islander
Ethnicity:        Hispanic           Non-Hispanic
Has family member served on active duty in the US Military?                Yes        No
Full-Time Student:      Yes           No




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                                              USHS Family Indication of Interest Form

Section I: Head of Household Information

        HoH Last Name:                                                        Suffix:
        HoH First Name:                                                       Alias:
          Middle Initial:


Family Member

Last Name                                                                     Suffix:
First Name:                                                                   Alias:

Relationship to Head of Household:

                                                                                                        Single
Social Security                                                               Marital Status:
Date of Birth:                                                                                          Married


Gender:           Male         Female


Race:       African America or Black        White   American Indian or Alaskan Native           Asian       Pacific Islander
Ethnicity:        Hispanic           Non-Hispanic
Has family served on active duty in the US Military?                         Yes        No
Full-Time Student:      Yes           No




Family Member

Last Name                                                                     Suffix:
First Name:                                                                   Alias:

Relationship to Head of Household:

                                                                                                        Single
Social Security                                                               Marital Status:
Date of Birth:                                                                                          Married


Gender:           Male         Female


Race:       African America or Black        White American Indian or Alaskan Native             Asian       Pacific Islander
Ethnicity:        Hispanic           Non-Hispanic
Has family member served on active duty in the US Military?                Yes          No
Full-Time Student:      Yes           No




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                                             USHS Family Indication of Interest Form

Section I: Head of Household Information

       HoH Last Name:                                                                    Suffix:
       HoH First Name:                                                                   Alias:
         Middle Initial:


Section II: Income

Total Monthly Income:

Client receives (check all that apply):                  SSI          SSDI        Disability Assistance


Client enrolled in (check all that apply):                      Medicaid          Medicare                Ohio SCHIP


Section III: Disabling Conditions/Special Needs
                              See "Certification of Disability" form for definition of "persons with disabilities."
Check all the disabling conditions that apply:
         Head of Household                                                            Spouse/Partner
          Physical Disability                                                          Physical Disability
          Developmental Disability                                                     Developmental Disability

          HIV/AIDS related diseases                                                    HIV/AIDS related diseases
          Mental Disability                                                            Mental Disability

          Alcohol Abuse                                                                Alcohol Abuse
          Drug Abuse                                                                   Drug Abuse


Please describe client's disabling condition:




STAFF MEMBER ONLY: Please describe any other factors you believe contribute to this client's need for
permanent supportive housing, including the extent and urgency of the need.




Other Special Needs:
          Long-Term Unemployment                                                       Recent Domestic Violence

           Other (please describe):




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                                             USHS Family Indication of Interest Form

Section I: Head of Household Information

       HoH Last Name:                                                                       Suffix:
       HoH First Name:                                                                      Alias:
         Middle Initial:

Section IV: Household Size

Do you anticipate any changes to your household size?                                  Yes (please describe below)   No




Section V: Housing and Homeless Status

Check one option that best describes the client's current living arrangement.
       Living in a place unintended for habitation (street, car, under bridge, etc.)

       Emergency shelter                                               Rental housing currently subsidized by CSB

       Transitional housing                                            Living with friends or relatives

      Psychiatric hospital                                             Rental housing

      Substance abuse treatment facility                               Doubled-up (couch surfing)
      Hospital Medical Unit                                            Other (please describe):
      Domestic violence situation


Section VI: Criminal Background

Has Head of Household or family member ever been convicted of a felony?         Yes      No
Has Head of Household or family member ever been convicted of a sex offense?
                                                              the illegal distribution or manufacture of an illegal
                                                                                     Yes       No
drug or other illegal controlled substances?
                                                             Yes             No
If YES to any of the questions above, please identify household member, offense and date of conviction.
         Household Member                                Offense                            Conviction Date




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                                             USHS Family Indication of Interest Form

Section I: Head of Household Information

       HoH Last Name:                                                                    Suffix:
       HoH First Name:                                                                   Alias:
         Middle Initial:

Section VII: Client Housing Preferences

Does client require an accessible unit?                         Yes (please specify accommodations below)          No




Potential applicant will not accept housing at the following projects:




Are there other needs/preferences regarding housing?                              Yes (please describe below)          No




Section VIII: Disclaimer and Verification

I/We understand that my/our completion of this Indication of Interest form does not guarantee me/us

I/We verify, under perjury of law, the above information provided by me/us in the USHS Indication of




                Head of Household Signature                                                                     Date


             Head of Household Printed Name




                  Spouse/Partner Signature                                                                      Date


               Spouse/Partner Printed Name


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