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Housing Opportunities Program (HOP) 501(c)(3)
Decatur Housing Authority
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Housing Choice Voucher Program
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About
Fort Wayne Housing Authority
Housing Opportunities Program (HOP) 501(c)(3)
Decatur Housing Authority
Housing Programs
Public Housing
Housing Choice Voucher Program
Tax Credit
Conventional
Community Development
Choice Neighborhoods Initiative
Supportive Services
Enrichment and Career Services
Family Self-Sufficiency Program
Homeownership Assistance Program
Fresh Start Enrichment Program
YouthBuild Academy
Homeless Prevention – Rental Assistance
Down Payment Assistance
Communities
Family Self-Sufficiency Program – Pre-Enrollment Form
Form Heading in the Large Heading with Content Section
Family Self-Sufficiency Program Pre-Enrollment Form
Head of Household Name
*
Address
*
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Date
*
Please list all family members who live in your housing unit, including the head of the household. Give the relationship of each family member to the head of household.
Name of Family Member
*
Relationship to Head of Household
*
Age
*
Sex
*
Male
Female
Ethnicity
*
White
African American
Hispanic
American Indian
Alaskan Native
Asian/Pacific Islander
plus1
Add Family Member
minus1
Remove Family Member
Are you (head of household) employed?
*
Yes
No
Job
Rate of Pay
Per
Hour
Week
If unemployed, what type of income do you receive?
Are any other family members employed?
*
Yes
No
Family Member
Job
Rate of Pay
plus1
Add Family Member
minus1
Remove Family Member
Please check any item below that you consider a current need. (Please check all that apply)
Need a Better Job
Need Someone to Take Care of Children (child care)
Need More Money to Pay Bills Each Month
Want to Finish School
Need Food Assistance
Job Training
Need Better Transportation
Need to See a Doctor for Health Problems
Need Help Being a Better Parent
Counseling
Need Help Managing Money
Please check any item below that you consider a current need
Please list other needs for services, or goals you or your family have:
Please check the different agencies you have visited or received services from in the last six months.
Health Department, Doctor or Clinic
Job Training Program
Mental Health Center
Food Pantry
Head Start for Child(ren)
Community College
Shelters
Community Action Agency or Community Services
Welfare Department
Alcohol or Drug Program
Children's Services Program
Vocational/Tech School
None of the Above
Other (please list)
Other (please list)
Do you speak English?
*
Yes
No
What language(s) do you speak?
Do other family members speak English?
*
Yes
No
If no, what language(s) do they speak?
Do you have a high school diploma or GED?
*
Yes
No
If you were to get a job or change your job, would you need help finding someone to watch your children (child-care)?
*
Yes
No
Do you now work with one person or a case manager who helps you and your family find the services you need?
*
Yes
No
If yes, please list the person's name:
What agency does she/he work for?
Ar you curently receiving Case Management Services from another agency?
*
Yes
No
If yes, what agency?
What are two or three of the biggest problems that YOU are facing now?
*
What are the two or three biggest problems currently facing YOUR FAMILY?
Signature
signature
keyboard
Clear
Email Address
*
Phone Number
*
Submit
If you are human, leave this field blank.