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What We Do / Housing / Motel 2 Home Application

Motel 2 Home Application

"*" indicates required fields

Head of Household Information

Each person listed must match birth certificate or driver's license.

Name*

First Last

What is your current living situation?*

If other, please provide details*

Have you been approved for housing?*

Yes

No

If yes, how much are move in costs?*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Email*

Gender*

Date of Birth*

Month

Day

Year

Ethnicity*

American Indian/Alaskan Native

Asian

African American

Caucasian

Hispanic/Latino

Native Hawaiian/Pacific Islander

Unknown

List the number of children under 18 in your household*

You must have a child under 18 in your home to qualify.

Marital Status*

How long have you lived in Georgia?

In what area would you like to look for housing?*

Spouse

Name

First Middle Last

Children and Other Occupants

How many children in household?*

Are there others in household (not dependent children)?*

Please list first and last name, date of birth and gender for each additional member in your household. (Do not include dependent children here. You can enter their information later.)

Child 1

Name

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Children's Information

Child 1

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 2

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Children's Information

Child 1

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 2

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 3

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Children's Information

Child 1

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 2

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 3

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 4

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Children's Information

Child 1

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 2

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 3

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 4

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 5

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Children's Information

Child 1

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 2

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 3

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 4

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 5

First Last

Date of Birth

Month

Day

Year

Name of School Attending

Child 6

First Last

Date of Birth

Month

Day

Year

Name of School Attending

If you have more than 6 children living in your household, please finish listing out the rest of the names below:

Residency History

Prior to staying in this extended stay, where did you live?

City, State or County

How long have you stayed in extended stay motels?

0-90 days

3-6 months

6 months-1 year

1-2 years

3+ years

How many times have you been evicted from housing as an adult?

Do you have unpaid rent or utility bills in your name?

What is your credit score?

Criminal Background

Have you ever been convicted of one or more misdemeanor(s)?

Have you ever been convicted of a felony?

Are you currently on probation?

Are you currently on parole?

Other Information

Do you have physical health or abilities issues?

Do you have mental health issues?

What is the highest level of education you have received?

Is English your second language?

What is your primary language?

Do you have a working car or other reliable transportation to get to work?

Do you have regular income from any of the following types of employment?

Are you currently receiving social security or disability?

If yes, how much social security or disability assistance do you receive each month?

Are you currently receiving child support from an ex?

If yes, how much child support do you receive each month?

Are you currently receiving food stamps?

Are you currently receiving financial assistance from a local nonprofit?

If yes, how much financial assistance do you receive from the local non profit and what is the assistance for?

How much is your household income each month?*

Add only income from employment for all adults in the household.

How much do you pay each month at your extended stay?

Do you have a checking account?

What bank do you have a checking account with?

Do you have financial debts (loan, cc, car payments, etc)?

Are you willing to work 1 on 1 with a caseworker for one year with the goal of maintaining stable housing?

Are you willing to complete periodic surveys to assess your housing progress?

Signature

By signing, the applicant represents that all of the above information is true and correct and hereby authorizes verification of the above items including, but not limited to, the obtaining of a credit report or background check. If any information is false, St. Vincent de Paul Georgia is entitled to reject the application.

Signature*

Untitled

First Choice

Second Choice

Third Choice

Comments

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Mission

Providing Help and Hope to Neighbors in Need

Location & Hours

2050-C Chamblee Tucker Road
Atlanta, GA 30341

Monday - Friday:
8:30 AM – 4:00 PM

Contact

Main: (678) 892-6160

Assistance: (678) 892-6163

Pharmacy: (678) 892-6181

info@svdpgeorgia.org

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