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					     Metropolitan Council Housing and Redevelopment Authority
     390 Robert St., North  Saint Paul Minnesota  55101



         BRIDGES AND SHELTER PLUS CARE INITIAL INFORMATION SHEET
Last Name                                    First                              Middle Initial


Mailing Address                                    City                                State              Zip            Phone #
                                                                                                                         (H)
                                                                                                                         (W)
E-mail Address


Name of Friend or Relative (Emergency contact)                                                                           Phone #

I heard about this program through:         An Outreach Worker County Staff Word of Mouth Other ________________

      HOUSEHOLD COMPOSITION: List each family member who will live with you. Include Social Security numbers for all
      members.

         Last, First, M.I.              Relation          Social Security           Date of       Age      Sex       List all that apply:        List all that apply:
                                        to Head              Number                  Birth
                                                                                                                      Race/Ethnicity                 S=Student
                                                                                                                      Codes (see codes              D=Disabled
                                                                                                                          below)
                                                                                                                       *R        **E                 V=Veteran

1.                                         Self


2.


3.


4.


5.


6.


      *Race Codes:           1. White                                                 **Ethnicity Codes:         1. Hispanic or Latino
                             2. Black/African American                                                           2. Not Hispanic or Latino
                             3. American Indian/Alaska Native
                             4. Asian
                             5. Native Hawaiian/Other Pacific Islander

      This information is required for statistical purposes so the Department of Housing and Urban Development (HUD) and Minnesota Housing may
      determine the degree to which its programs are utilized by Minority families. The General Counsel of HUD has ruled that the regulation issued
      on behalf of the Secretary requiring collection of racial and ethnic data has the force and effect of law, and takes precedence over any conflicting
      state and local requirements.
                                                                                                    SPC & BR

Name of Case Manager if applicable (required for Shelter Plus Care applicants):


 Agency name:


 Address:


 Phone number:

Name of Community Support Service, if applicable:



Phone number:


 Name of crises assistance organization, if applicable:



 Phone number:


Questions about your household/living arrangements (Answer ALL of the following questions):
 Current Address,
 If different from Mailing Address:
 City:                              State:                                  Zip:
 County:                            Home Phone:                             Work Phone:
Yes    No
               1. Does anyone live with you who you did not list under Household Composition (pg. 1)?
                       If yes, please explain: __________________________________________________
               2. Is any member currently absent but will be living with you in the future?
                       If yes, please explain: __________________________________________________
               3. Do you plan to have anyone living with you in the future who is not listed on pg. 1?
                       (i.e., you have shared custody of a dependent, temporarily absent adult family
                       member, or a household member who is pregnant or anticipating adoption of a child?)
                       If yes, please explain: __________________________________________________
               4. Are the minors listed in your household living with you more than 50% of the time?
                       If no, please explain:
               5. Did you list any member on pg. 1 as Disabled = “Y”. If yes, please identify special
                       housing needs required as a result of the disability: ___________________________
               6. Does any member require a specific accommodation to fully utilize our programs or
                       services? If yes, please explain: __________________________________________
               7. Does any member of your household have elevated blood levels due to lead
                       poisoning?        Never been tested
               8. Are you now living in a government subsidized unit? (i.e., Public Housing, Section 8,
                       Section 23, Section 42, 232, or Section 221 (d)(3) subsidized projects)
                       If yes, please explain: __________________________________________________
           9. Have you ever lived in Public Housing?
                   If yes, where?: __________________ Approx. dates: __________________
           10. Have you ever participated in the Section 8 Rental Assistance Program?
                   If yes, where?: __________________ Approx dates: __________________
           11. Have you or any household member been evicted from public housing or
                   terminated from a Section 8 rental assistance program?
                   If yes, please specify approximate date:_____________________________________
           12. Do you or any household member currently owe money to any public housing agency in
                   connection with Section 8 or public housing program? If yes, specify which PHA:
                   ____________________________________________________________________

INCOME INFORMATION: ANSWER ALL OF THE FOLLOWING QUESTIONS
Yes   No   Do you or any member of your household:
           1. Work full-time, part-time or seasonally?
                   If seasonally, please explain: _____________________________________________
           2. Expect to work for any period during the next twelve months?
           3. Work for someone who pays you, him or her in cash?
           4. Provide care-taking or other services for the property you live in?
           5. Have you or any member of your household worked in the last twelve months?
                   If so, when and where: _________________________________________________
           6. Are you or any member of your household on leave of absence from work due to lay-off,
                   medical, maternity, or military leave?
           7. Do you or any member of your household participate or expect to participate in a job-
                   training program?
           Do you or any member of your household now receive, or expect to receive:
           8. Income from self employment?
           9. Unemployment benefits?
           10. Disability insurance?
           11. Worker‟s compensation?
           If you checked „Yes” to items 7, 8, or 9 above, what do you plan to do for an income source
           when the benefit runs out? _____________________________________________________
           12. Income from babysitting/childcare services?
           13. Economic assistance such as MFIP, GA and/or MSA?
           14. Social Security or SSI benefits?
           15. Income from a pension or annuity?
           16. Income from assets including interest on checking or savings accounts, interest and
                   dividends from certificates of deposit, stocks or bonds, income from the rental of
                   property?
           17. Child support? Check her if you are entitled to support but not receiving it:
           18. Alimony payments?
           19. Regular cash contributions from individuals not living in the unit or from agencies and/or
                   does anyone outside your household regularly pay for any of your bills or give you
                   money?
           20. Income from any athletic scholarship?
                   20 a. If yes, is a portion of the scholarship specifically made available to you for
                   general living expenses such as room and board?
                   20 b. Is there any money left from the scholarship income after you pay your
                   monthly tuition, fees, books, equipment, materials, supplies, transportation, and
                   miscellaneous personal expenses related to school?
FOR EACH “YES” IN THE INCOME INFORMATION SECTION, PROVIDE DETAILS BELOW:
                              (LIST ALL INCOME BELOW)
                       Source (i.e. Employment, Child Support, Pension, SS,    Gross Income
 Household Member                        SSI, MFIP, etc.)                   (per week, month, or
                        Please provide complete name, address, state and           year)
                                          zip of source.
                                                                            $       per

                                                                                          $         per

                                                                                          $         per

                                                                                          $         per

                                                                                          $         per

                                      (use additional page if necessary)

ASSET INFORMATION: ANSWER ALL THE FOLLOWING QUESTIONS

Yes    No     Does any member of your household have:
              1. Cash on hand over $100?
              2. Any checking accounts?
              3. Any savings accounts?
              4. Any certificates of deposit?
              5. Any annuities?
              6. Any money market funds?
              7. Any IRA, Keogh, 401K, 403B or other retirement accounts that you have access to?
              8. Any stocks/bonds/mutual funds?
              9. Any U.S. Savings Bonds?
              10. Any life insurance policies with a cash value?
              11. A contract for deed?
              12. Own any real estate and/or mobile home?
              13. Own a business?
              14. Have you sold or given away any assets for less than their fair market value in the past
                      two years? If yes, explain: _______________________________________________
              15. Do you own any personal property, which is held for investment purposes? (Example:
                      gems, jewelry, antiques, silver, gold coin/gun collection, etc.) If so, describe and give
                      current appraised value.
                      Description: __________________________________________________________
                      Current appraised value: $_________
  FOR EACH “YES” IN THE ASSET INFORMATION SECTION, PROVIDE DETAILS BELOW:
                                   (LIST ALL ASSETS BELOW)
                    Description of Financial Institution – name, address, Account Number   Current
Household Member   Asset (savings,        city, state and zip code                         Balance
                   checking, bond,
                        IRA)
                                                                                         $

                                                                                                                       $

                                                                                                                       $

                                                                                                                       $




WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or
misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction.
 I certify that all information I have given on this form is complete and accurate.
 I have listed all members of the household and all sources of income and assets, earned and unearned, for all members of my
    household.
 I understand that providing false information will result in the termination of my rent assistance.


   _________________________________________________                                         ______________
   Signature of Head of Household                                                            Date
   _________________________________________________                                         ______________
   Signature of Other Household Member Age 18 and Over                                       Date
   _________________________________________________                                         ______________
   Signature of Other Household Member Age 18 and Over                                       Date

   NOTE TO APPLICANTS: If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity
   National Toll-Free Hotline at 800-424-8590. (Within the Washington, D.C., metropolitan area, call 426-3500).

   If you require these documents in an alternative format, please call Metro HRA at (651) 602-1428.

                                               This is important housing information.
                                If you do not understand it have someone translate it for you now.
                                          Información importante acerca de las viviendas.
                                 Si usted no lo comprende, pida a alguien que le traduzca ahora.
                                        Qhov no yog lus tseem ceeb heev qhia txog tsev nyob.
                                   Yog tias koj tsis tau taub thov hais rau lwm tus pab txhais rau koj.
                                               Это важная информация о жилпощади.
                            Если Вы её не понимаете, попросите кого-нибудь сейчас перевести её Вам.
                                        Kani waa warbixin muhiim ah ee ku saabsan guriyaha.
                              Haddii aadan fahamsaneyn waa in aad heshaa hadeertaan qof kuu tarjumaa

				
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