HOUSING ASSISTANCE REQUEST FORM

 

The ILP program provides housing assistance in monthly increments with a maximum of three month’s assistance. We do not automatically process your paperwork and assure payment.  You will need to submit a written request with an explanation for every month you require assistance.

 

The following paperwork must be submitted with your application:

 

 

SECTION 1: GENERAL INFORMATION

 

Name:                                                                                      Date                                                   

 

Address:                                                                       City ____________________ State               

 

ZIP Code: _________________         Phone#_________________ Message#:                                

 

Previous Social Worker/Probation Officer: ____________________ Phone#:                         

 

D.O.B._____________________SSN#                                                                                                                     Age                                                                 

 

Ethnicity: ______________________________Primary Language                                                     

 

Are you married? _______Do you have children? _______If yes, how many?                         

 


SECTION 2: EDUCATIONAL INFORMATION

 

Do you have a high school diploma or equivalent?                     YES     NO

 

High School graduated from:                                                     Month/Year                                         

 

College or school attending:                                                      Major                                                  

 

Date you are expecting to complete your education or training:                                                  

 

Have you applied for financial aid? ________Has financial aid been approved?                        

 

If so, how much financial aid do you receive per semester?                                                                   

 

Are you registered at the One Stop Center?                                                          YES        NO

 

If so, have you ever participated in any program or training                                                                                                                                                                                                                               

 

 


SECTION 3: HOUSING INFORMATION

Housing History:  (List the 2 most recent housing arrangements)

From

To

Apartment or Studio

Roommates

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

Have you ever received assistance from the Independent Living Program? (For housing, school tuition, household items, computer, etc.)                                                                                                                                                                                                                                                

If you have received housing assistance, for how many months did you receive aid?                   

Have you applied for assistance at the Housing Authority?                     YES    NO

Have you ever been evicted from an apartment or studio?                YES    NO

If so, briefly explain                                                                                                                              

Have you ever rented an apartment or studio on your own?                   YES     NO

If so, briefly explain the results:                                                                                                 

Have you ever shared an apartment or studio with a roommate?            YES     NO

If so, briefly explain the results:                                                                                                 

 

Will you need assistance in finding affordable housing?               YES     NO

If so, in what city are you hoping to locate housing?                                                                              

Are there any other areas that you would consider?                                                                              

What living arrangement are you seeking? (Check the appropriate box)

___With friends   ___Apt   ___Condo   ___House   ___Other:                                                           

If you have already found an apartment or studio, how much is the rent?                                               

What utilities are included?                                                                                                                   

If living with a roommate or roommates, what is your share of the rent?                                     

If applicable, name of housing complex or business:                                                                  

Contact person: ___________________________________ Phone#:                                               

How will you be paying for the rent after the period of assistance?                                                                                            

 

 

 

 


SECTION 4: EMPLOYMENT & FINANCIAL INFORMATION

From

To

Employer

Position

Hourly

Wage

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

Are you employed or enrolled in an employment program?                                 YES          NO

If currently employed, how many hours do you work per week?                                                           

How much do you earn per month? ____________Do you have a car?                                               

Do you currently have a savings or checking account?                                                              

List any additional monthly bills: (car payment, cell phone, etc.)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

Do you have any other source of income? If yes, briefly describe: (social security, welfare, financial aid, etc.)                                                                                                                             

I authorize the Imperial Valley Regional Occupational Program to share this information with other county agencies. This information will only be used

 

Signature: __________________________________________Date:                                           

 

 


YOUTH STATEMENT

 

Youth statement instructions: Read the following essay guidelines and write a short essay in a separate sheet of paper.  Write at least three paragraphs and attach your essay to the completed application. The essay can be handwritten or typed.

 

1.      1st Part-Brief history of yourself and current situation. Mention the reason you are requesting housing assistance.

2.      2nd Part- Tell us about yourself. Mention the school you attend, where you work, if involved in any programs and any short-term goals you have (within next year).

3.      3rd Part- Tell us about your plans for the future, career interests, educational goals and long-term goals you have (5 or more years from now).

4.      Final part-Tell us how you plan on being financially secure after the period of assistance.

SUBMIT APPLICATION AND REQUESTED DOCUMENTS AS SOON AS POSSIBLE