Comments

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Today's Date

NOTE: Healthy Housing does NOT provide Rental Assistance. Please reach out to local nonprofits like United Way, Together, Inc, St. Vincent de Paul, etc. and local churches, to help you with rent.

Renter Information

Applicant Name*

First Last

Preferred Language*

Applicant Address*

Street Address City State ZIP Code

County*

Insurance type*

Contact Information

Applicant Phone*

Applicant 2nd Phone

Applicant Email

Do you have a co-applicant?*

Yes

Co-Applicant Name*

First Last

Co- Applicant Phone*

How Can We Reach You?

We are so excited about your interest in the Healthy Housing Program. Please let us know how best to contact you.

Preferred Methods of Contact*

Phone Call

Text

HOUSEHOLD MEMBERS & INCOME

Please list all household members who are living at this address. Please list all household income for adults over 18 who are not full time students. NOTE: Do NOT click the "+" sign.

1- Head of Household*

1- Date of Birth*

1- Race/Ethnicity*

1- Relationship to Applicant*

1- Disability*

Yes

1- Please enter your YEARLY income*

Do you have a 2nd person living in the house?*

Yes

2- Household Member*

2- Date of Birth*

2- Race/Ethnicity*

2- Relationship to Applicant*

2- Disability*

Yes

2- Please enter your YEARLY income*

Do you have a 3rd person living in the house?*

Yes

3- Household Member*

3- Date of Birth*

3- Race/Ethnicity*

3- Relationship to Applicant*

3- Disability*

Yes

3- Please enter your YEARLY income*

Do you have a 4th person living in the house?*

Yes

4- Household Member*

4- Date of Birth*

4- Race/Ethnicity*

4- Relationship to Applicant*

4- Disability*

Yes

4- Please enter your YEARLY income*

Do you have a 5th person living in the house?*

Yes

5- Household Member*

5- Date of Birth*

5- Race/Ethnicity*

5- Relationship to Applicant*

5- Disability*

Yes

5- Please enter your YEARLY income*

Do you have a 6th person living in the house?*

Yes

6- Household Member*

6- Date of Birth*

6- Race/Ethnicity*

6- Relationship to Applicant*

6- Disability*

Yes

6- Please enter your YEARLY income*

Do you have a 7th person living in the house?*

Yes

7- Household Member*

7- Date of Birth*

7- Race/Ethnicity*

7- Relationship to Applicant*

7- Disability*

Yes

7- Please enter your YEARLY income*

Do you have a 8th person living in the house?*

Yes

8- Household Member

8- Date of Birth*

8- Race/Ethnicity*

8- Relationship to Applicant*

8- Disability*

Yes

8- Please enter your YEARLY income*

Landlord/Property Owner Information

Please fill out this section to the best of your knowledge.

Disclaimer: By providing the property owner information, you give Lutheran Family Services- Healthy Housing permission to contact your landlord to request participation in our Healthy Housing program. Please note that only your name and the property address will be shared. No additional personal information will be disclosed without your further consent.

Note: Landlord/Property owner must agree to be a part of this program or Healthy Housing is unable to provide services.

Landlord/Property Owner Name*

First Last

Landlord/Property Owner Phone*

Landlord/Property Owner Address*

Street Address City State ZIP Code

Landlord/Property Owner Email*

Property Information

Type of Property*

Please select the type of property.

If it's a multi-family unit, how many units are there?*

Section 8 Housing*

Yes

Name of Housing Authority*

How did you hear about us or what agency referred you?*

What are your concerns about your home?*

NOTE: Answering yes will not impact your application approval. However, failure to disclose any pests could impact your eligibility in our programs.

Do you have any pests (roaches, mice, bedbugs, fleas, etc.) currently in your home?*

Yes

Please CLICK on every pest that is currently in your home.*

INDEMNIFICATION. The Client agrees to indemnify, defend, and hold harmless Lutheran Family Services- Healthy Housing , including its board of directors, officers, employees, agents, and affiliates (collectively, the "Indemnified Parties"), from and against any and all claims, liabilities, damages, losses, costs, expenses (including reasonable attorneys' fees), judgments, fines, and penalties arising out of or related to the Client's use of Healthy Housing's services. This indemnity covers, but is not limited to, any damages or liability arising from the Client's breach of this Agreement, negligence, willful misconduct, or any other action by the Client that results in harm or liability. The Indemnified Parties shall not be liable for any indirect, special, incidental, consequential, or punitive damages, including lost profits, arising out of or in connection with this Agreement or the services provided hereunder. The Client's obligation to indemnify the Indemnified Parties shall survive the termination or expiration of this Agreement."

Signatures- By typing in your name, today's date, and clicking "Submit", you agree that all the information is true to the best of your knowledge. I understand that completing the application process is no guarantee of receiving funding.

Are you filling this form out on behalf of someone other than yourself?*

Yes

Name of individual completing application on behalf of applicant.*

First Last

Organization*

Job Title*

Proxy Phone Number*

Proxy Email*

Name of Applicant*

First Last

Is there a co-applicant?*

Yes

Name of Co-Applicant*

First Last

Signature*

Date*

Renter Intake Form

Expert Form Tip: Sync with an Email Add-On

NOTE: Healthy Housing does NOT provide Rental Assistance. Please reach out to local nonprofits like United Way, Together, Inc, St. Vincent de Paul, etc. and local churches, to help you with rent.

Renter Information

Contact Information

How Can We Reach You?

HOUSEHOLD MEMBERS & INCOME

Landlord/Property Owner Information

Property Information

NOTE: Answering yes will not impact your application approval. However, failure to disclose any pests could impact your eligibility in our programs.

Signatures- By typing in your name, today's date, and clicking "Submit", you agree that all the information is true to the best of your knowledge. I understand that completing the application process is no guarantee of receiving funding.

If you have an emergency or medical need:

Setup appointment or start virtual care:

Expert Form Tip: Sync with an Email Add-On

NOTE: Healthy Housing does NOT provide Rental Assistance. Please reach out to local nonprofits like United Way, Together, Inc, St. Vincent de Paul, etc. and local churches, to help you with rent.

Renter Information

Contact Information

How Can We Reach You?

HOUSEHOLD MEMBERS & INCOME

Landlord/Property Owner Information

Property Information

NOTE: Answering yes will not impact your application approval. However, failure to disclose any pests could impact your eligibility in our programs.

Signatures- By typing in your name, today's date, and clicking "Submit", you agree that all the information is true to the best of your knowledge. I understand that completing the application process is no guarantee of receiving funding.

Get Help Now

If you have an emergency or medical need:

Setup appointment or start virtual care: