Endaad Program Application

Today's date*

Date

Program Location(s)*

Women’s North Minneapolis transitional housingMen's South Minneapolis transitional housingMen's sober housing, Mahnomen, MN (White Earth Reservation)Men's sober housing, Waubun, MN (White Earth Reservation)Other

Do you have children in your care?

YesNo

How many are in your care that would be living with you?

1234 or more

What is the age of your child? Please list the age of each child in your care that would be living with you.

Do you have any restrictions regarding being around children/minors?*

YesNo

Requested move in date*

Date

Were you referred to the program?*

YesNo

Agency

Referred by

First NameLast Name

Referrals phone number

Area CodePhone Number

Referrals email

example@example.com

Applicant's Name*

First NameMiddle InitialLast Name

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Veteran

YesNoOther

Applicant Email

example@example.com

Primary Phone Number*

Area CodePhone Number

Who's number*

Okay to leave message?*

YesNoOther

Secondary Phone

Area CodePhone Number

Who's number

Okay to leave message?

YesNoOther

Additional Phone

Area CodePhone Number

Who's number

Okay to leave message?

YesNoOther

Social Security Number

Helps us check public assistance eligibility.

MA Number, if known.

Date of Birth*

Date

Age*

Gender*

Race (select all that apply)*

Enrolled Tribal Member?*

YesNoUnsure

Enrolled Tribe*

Descendant of a Tribe?*

YesNoUnsure

Also a descendant of another Tribe?*

YesNoUnsure

Tribal Affiliation 1*

Tribal Affiliation 2

Current Living Situation:

Currently Employed?*

YesNoOther

Employment History

	Employer	State Date
Entry 1
Entry 2

Monthly Income*

	Monthly amount, or enter 0
Social Security (SSI / SSDI)
GA or MFIP
Employment
Tribal Payments
Unemployment
MSA
Veterans Benefits
Retirement / Pension
Other

Assets*

	Amount / Value, or enter 0
Checking / Savings
Money Market
Stocks, bonds, mutual funds
Trusts
Real Estate Interests
Personal property investments
Business ownership
Vehicle ownership
Other

Do you have any evictions on your record?*

YesNoOther

Do you have a criminal record?*

YesNoOther

Please explain*

Do you have any sex offenses?*

YesNoOther

Do you have to notify the community?*

YesNoOther

If yes, please explain*

Are you on probation or supervised release?*

YesNoOther

Most recent offense?

Supervision County

Agents or release planner's name

First NameLast Name

Agents or release planner's Phone Number

Area CodePhone Number

Agents or release planner's email

example@example.com

Do you have barriers to finding housing?*

YesNoOther

If yes, please explain*

Households Experiencing Long-Term Homelessness (Minnesota): Individuals who lack a permanent place to live continuously for a year or more, OR at least four (4) times in the past three (3) years. Any period of institutionalization or incarceration shall be excluded when determining the length of time an individual has been homeless.

Doubled Up/Couch Hopping: Doubled up or couch hopping is considered an episode of homelessness if a person is doubled up with another household (and duration is less than one year) or couch hops as a temporary way to avoid living on the streets or an emergency shelter.
Transitional Housing: Time spent in transitional housing (TH) is a neutral event. Housing history prior to or after transitional housing should be evaluated to determine if it meets the state’s LTH definition. For example, if a household was homeless eight (8) months prior to entering TH and four (4) months after existing TH, the household would meet the LTH definition.
Exclude institutions and incarceration: Any period of institutionalization or incarceration shall be excluded when determining the length of time a household has been homeless.

During the past three (3) years have you been?*

Homeless continuously for one (1) year or moreHomeless four (4) or more times over the past 3-yearsI do not qualifyOther

Disabling condition*

Do you require special care, assistance, or special accommodations?*

YesNoOther

If yes, please explain*

Person Completing Form*

Self/ApplicantFriend/Family MemberProfessional

Name

First NameLast Name

Relationship

Agency, if applicable.

Phone 1

Area CodePhone Number

Phone 2

Area CodePhone Number

Fax Number

Area CodePhone Number

Person Completing Form Email*

example@example.com

Release of information upload

Browse Files

please upload your release for this client

If available, Professional Statement of Need upload

Browse Files

please upload if available

Relevant assessments/ case notes upload

Browse Files

please upload if available

With my signature below, I certify that the information provided on this application is accurate and complete to the best of my knowledge and belief. I understand that false statements or information are punishable under Federal Law. I also understand that false statements or information are grounds for denial and termination of housing assistance and termination of tenancy. I understand that ANY changes to the application must be reported in writing to Anishinaabe Endaad property management within 10 days of the change.

Signature*

Anishinaabe Endaad Program Application

Demographics

Income / Assets

Criminal History

Long-Term Homeless Verification

Disability Information

Contact(s) Information

Signature Page