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Housing Unlimited, Inc. Application |
The Housing Unlimited, Inc. Application Packet contains the following documents and requires income verification.
To complete your application packet, please make sure to include all of the
following forms and income verification (pay stubs, SSI award letter):
- Housing Unlimited Application Form
- Housing History Form
- Application Preferences Questionnaire
EXAMPLE APPLICATION (Please click on "Housing Unlimited Application Form" above for a printable version)
Please FAX or MAIL this completed form to Housing Unlimited, Inc
Housing Unlimited, Inc.,1398 Lamberton Drive, Suite G1, Silver Spring, MD 20902
Questions? Contact Housing Unlimited, Inc. at 301-592-9314 (fax) 301-592-9318
General Information:
Applicant Name: ________________________________________________SSN: _____________________________________
Date of Birth: ______________________________________________Age: _________________ Sex: ______ M ______ F
Race: ________________________ Medical Assistance #: _____________________________ Veteran: ___ Yes ___ No
Current Address: (street)______________________________________________________________________________________
(city/state/zip)________________________________________________________________________________
Home Phone Number: ________________________________ Work Phone Number: _____________________________________
Cell Phone Number: __________________________________ E-mail Address: _________________________________________
Income (Monthly) $__________________ Source*: ______________________________________________________
*Please attach verification of the above income such as current pay stubs or a current social security award letter.
HUI requires applicants to have a minimum monthly income of $400 by the time they reach the top of the waitlist.
(Housing Unlimited's mission is to serve adults with psychiatric disabilities)
I certify that I have a psychiatric disability:
_____________________________
Signature Date
Emergency Contact Person(s):
(1) Relative's Name: _______________________________________________ Relationship: ___________________________
Address: ______________________________________________________ Phone: ________________________________
(2) Name: ________________________________________________________ Relationship: ___________________________
Address: ______________________________________________________ Phone: ________________________________
(3) Name: ________________________________________________________ Relationship: ___________________________
Address: ______________________________________________________ Phone: ________________________________
Housing History:
On the back of this application, please provide the following information:
1. Please list all your home addresses for the past ten years and include dates of residence.
2. For all home addresses in the past twelve months, please include landlord contact information.
Housing Preference*:
Would you prefer the camaraderie and peer support of living in a large, coed home with four other housemates? __ Y __N
Would you prefer to live in a smaller, single-sex home with one or two other housemates? ___Y ___ N
Would you like to be considered for all HUI housing-- large coed homes and small single-sex homes? _____Y _____N
Do you have specific individuals whom you would like to have as housemates*? If so, please list their names:
___________________________________ ___________________________________________
*HUI will attempt to accommodate applicant housing preferences; however, HUI makes no guarantee that it will be
able to offer an applicant his/her housing preference.
Background Check:
Have you ever been convicted of a crime? ____Y ____ N If so, please describe the date and circumstances
on the back of this form.
As part of the application process, Housing Unlimited, Inc. conducts a routine criminal background check
of all applicants in accordance with HUI
policy. Your signature below indicates your understanding that HUI will conduct a criminal background check.
___________________________________________ ______________________________________
Applicant Signature Date
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