FOND DU LAC SUPPORTIVE HOUSING Operated by the Fond du Lac Band of Lake Superior Chippewa APPLICATION FOR SUPPORTIVE HOUSING VETERAN S HOUSING BOTH Personal Information: Applicant Social Security # Previous name Date of Birth Co-Applicant Social Security # Previous name Date of Birth Household Composition: Member Full Name Relationship to Head Date of Birth Age Gender Social Security # 1. HEAD 2. 3. 4. 5. 6. If you anticipate any changes to this household in the next twelve months, please explain: General Occupancy Guidelines: Occupancy guidelines have been designed to avoid overcrowding and underuse of a unit. Number of Bedrooms Number of Persons (Min) Number of Persons (Max) 0 1 1 1 1 2 2 2 4 3 3 6 Bedroom size requested based on General Occupancy Guidelines: Efficiency or 0 Bedroom 1 Bedroom 2 Bedroom 3 Bedroom Contact Information: Mailing Address (where you can receive mail) City State Zip Code Phone Number(s): Please include message phone number(s) where we could get a message to you RBC Approved 5/15/2018 1
Is any household member a: Fond du Lac Band of Lake Superior Chippewa enrollee Yes No Household Member Tribe Enrollee Number FDL or a child/grandchild of a Fond du Lac Enrollee? American Indian enrolled in a Federally recognized tribe located in the State of Minnesota? American Indian enrolled with a Federally recognized tribe of another state? Yes No Yes No Yes No FDL Name of enrolled Band Member Relationship Veteran Status: U.S. Military Veteran? Yes No Months served on active duty in the military: Discharge Type: Honorable General Medical Bad Conduct Dishonorable Other Military Service Related Disability? Yes No Receiving Veteran s Services? Yes No If Yes, list Veteran s Services from list below: 1) 2) WW I WWII & Korean War Vietnam Army Air Force Marines Navy Coast Guard National Guard Does applicant have a disability of long duration? Yes No Don t know Refused If yes, please describe: Does your household have any needs that might be better served by an apartment which is accessible to persons with mobility, hearing, or visual impairments? If yes, explain: Domestic Violence Survivor? Yes No If yes, when was the domestic violence? Within the past 3 months From 6 to 12 months ago 3 to 6 months ago More than a year ago Don t know Refused If violence is past, and you would like to access resources to help further your healing, please let us know and we will help you access them. 2
Homelessness Information Extent of Homelessness (check 1) Not currently homeless 1 st time and less than 1 yr. without a home 2 nd or 3 rd time in past 3 years at least 1 year OR at least 4 times in the past 3 years Leave any of these in the last 90 days? No: skip to next question Yes: circle the most recent Adoptive Home Orphanage Foster Home Group Home (youth only) Juvenile Detention Center Drug/ Alcohol Treatment Facility Halfway House Mental Health Hospital or facility County Jail or workhouse State or Federal Prison Residence for people with physical disabilities Living situation last night (circle 1) corrections facility hotel/motel on the street substandard housing detox with family owns home transitional housing domestic violence shelter with friends rental house/apartment emergency shelter mental health facility subsidized housing hospital nursing home substance abuse treatment center other/unknown: Length of stay: One week or less More than one week, less than one month 1 to 3 months More than 3 months, less than one year One year or longer Last permanent address: How long since you ve had a permanent place to live? Less than one month 1-3 months 3-6 months 6-12 months 1-2 years 3-5 years 6-8 years 9 years or more Date left last residence: Homelessness Reason: indicate P for one primary reason, S for one secondary reason. criminal activity loss of job mortgage foreclosure substandard housing domestic violence loss of public assist. no affordable housing low income eviction loss of transportation personal/family crisis utility shutoff health/safety medical condition release from institution loss of childcare mental health substance abuse other 3
Have you owned your own home in the last 3 years? Yes No Have you rented in the past 3 years? Yes No Has any household member had an eviction filed against them or been asked to leave? Yes No List all places you have lived in the past three (3) years: If you need more space use back of page. 1. 2. 3. 4. Criminal History: Yes No Has any household member ever been convicted, plead guilty or no contest to a felony? Yes No Has any household member ever been convicted, plead guilty or no contest to the illegal use, manufacture, or distribution of a controlled substance? Yes No Has any household member ever been convicted, plead guilty or no contest to a misdemeanor involving sexual misconduct, assault, criminal damage to property, stalking, harassment, gang related activities or any other crimes of physical violence to persons or property? Yes No Is any household member a registered sex offender? Yes No Is any household member currently actively using an illegal or controlled substance? Yes No Does any household member have ANY pending criminal charges? If you answered yes to any question in this section, please explain: Provide Personal References that have known the household for at least three years or a referring social service agency. (Personal references are to be someone other than family members and landlord references) NAME COMPLETE MAILING ADDRESS PHONE NUMBER 1) 2) Referral Source (How did you hear about Fond Du Lac Supportive Housing?) Counselor/Social Worker Family/Friends OTHER: Income: Do you or any household member have income? Yes No 4
Is income received from any of the following sources: (Circle Yes or No) Applicant Co-Applicant Monthly Amt Social Security/SSI/RSDI/Disability Yes No Yes No $ Pension/Annuity Yes No Yes No $ Veteran s Benefits Yes No Yes No $ Unemployment Yes No Yes No $ Workman s Comp Yes No Yes No $ MFIP/Public Assistance/ GA Yes No Yes No $ Per Capita payments Yes No Yes No $ Employment Yes No Yes No $ Child Support Yes No Yes No $ Military Pay Yes No Yes No $ Self-Employment Yes No Yes No $ Contributions from family and/or friends Yes No Yes No $ Income from assets Yes No Yes No $ Other Income Yes No Yes No $ Grants or scholarships Yes No Yes No $ Assets: Applicant Co-Applicant Checking Account Yes No Yes No Savings Account Yes No Yes No Cash Cards used to receive benefits Yes No Yes No Stocks, Bonds, Trusts, Securities, CD s Yes No Yes No Life Insurance Whole or universal Yes No Yes No 401K, IRA/Keogh Accounts Yes No Yes No Treasury Bills Yes No Yes No Real Estate Yes No Yes No Are assets held jointly with another person Yes No Yes No Have you sold or given away any assets for less than Fair Market Value during the previous two years preceding the date of this application? Any assets sold or disposed of for less than Fair Market Value must be identified below: Household Member Asset and estimated Market Value Date sold/disposed Amount Rec d Emergency contact(s) Name: Address: Name: Address: Phone: Relationship: Phone: Relationship: 5
Applicant please note: Filing of this application does not obligate the applicant in any way. Neither does it obligate Fond du Lac Supportive Housing to commit to or guarantee the applicant a rental unit at the complex. The determination to rent to the applicant will be made on the basis of the applicant s determined eligibility and the availability of an appropriate size unit in accordance with the Tenant Selection Criteria. By signing this application: I/We certify that all information in this application is true to the best of my/our knowledge and that I/we understand that false statements or wrong information is punishable by law and will lead to cancellation of the application or termination of tenancy after occupancy. I/We do hereby authorize Fond du Lac Supportive Housing and/or Fond du Lac Housing and their staff or authorized representatives to contact any agencies, offices, groups, individuals or organizations to obtain information and verify any information or materials which are deemed necessary to complete my/our application for housing at the property listed at the top of this application. Applicant(s) certify that the unit applied for will be the applicant(s) permanent household address and the applicant(s) will not maintain a separate subsidized rental unit in a different location. Signature: Date: Applicant Signature: Date: Co-Applicant 6
RESIDENT SELECTION CRITERIA FOND DU LAC SUPPORTIVE HOUSING INTRODUCTION: Supportive Housing reserves the right to reject anyone that may jeopardize the future stability of the property. To be eligible for occupancy, applicants must meet the following selection criteria: A. Appropriate Family Size - The family size must be appropriate for the unit available. B. Income - The household s income must fall within the established income guidelines depending on the available unit. (See Appendix). C. Homeless Status - The household must meet the definition of homeless or long-term homeless or chronically homeless depending on the available unit- which are defined as follows: Homeless: A household lacking a fixed, adequate night time residence (includes doubled up). -OR- Long-Term Homeless: 1) A person, family or youth who has been on the streets or in a shelter for a year or more (Time spent in an institution or similar establishment does not count as time housed or time homeless) 2) A person, family or youth who has been on the streets or in shelter at least four times in the past three years 3) A person, family or youth who has been couch hopping for at least a year (moving from one place to another with no permanent place to stay). Note: if a person has been staying with the same family or friend even if for a year or more the person is not considered homeless as the person s living situation is considered to be stable -OR- Chronically Homeless: 1) A homeless individual or family with children with a disabling condition (adult) who has either been continuously homeless for year or more, or has had at least four episodes of homelessness in the past three years. D. Criminal Activity - Applicants and their household members shall have no criminal history involving crimes against persons or property. Conviction for crimes of physical violence, property damage, theft, drug related offenses, sexual offenses, or any other act that would be detrimental to the health, safety or welfare of other residents or their peaceful occupancy of the premises will be grounds for denial as set forth in Fond du Lac Ordinance #02/09 or applicable federal law. Conviction of crimes for sexual offenses will result in a lifelong denial. Conviction of crimes for felonies will result in a denial period of 10 years. The following exceptions to felony and non-felony convictions shall apply: 1) Drug related felony convictions will be considered if they are older than three (3) years and there are no same or similar incidents whether convictions or charges for the prior three year period. 2) Non-felony drug or domestic assault convictions will be considered if the conviction is older than two (2) years and there are no same or similar convictions or charges for the prior two year period. 7
E. Rental History - It will be grounds for denial if Applicant's rental history shows a record of disruptive or violent behavior or shows a record of destruction of property. F. Credit - Applicants for the FDL Veterans Supportive Housing units must have the ability to transfer utilities into the name of the adult G. No demonstration of Negative Behaviors- If applicant exhibits any of the following, it can be used as grounds for denial: display of uncooperative, abusive or belligerent attitude towards management and/or members of an interviewing committee during the application process; providing information on application or in interview which is false, misrepresented, incomplete or non-verifiable. DENIAL OF APPLICATION: In the event any application is not approved, the applicant shall be notified, in writing, by first class mail as to the reasons for non-selection and whom to contact for additional information. HOLDING A UNIT: After receiving notification of approval for occupancy, an applicant must pay the necessary deposit to hold the unit. Any deposit paid at this time will be applied to the damage deposit when the applicant occupies the unit. Unless the deposit is paid there is no guarantee of rental and management will continue to process applications for the unit. If applicant fails to occupy the unit, the deposit will be forfeited as liquidated damages. Prior to move-in, each applicant must pay the security deposit and first month s rent. VERIFICATION: All information for admission will be verified by third parties. Applicants must furnish written authorization for required verifications from a THIRD PARTY. Applications are not considered complete until all required verifications have been obtained. WAITING LIST: Where applicable, a waiting list will be maintained. Signature Signature Date Date 8
APPENDIX FOND DU LAC SUPPORTIVE & FOND DU LAC VETERANS SUPPORTIVE HOUSING LONG-TERM HOMELESS/CHRONIC HOMELESS Income Guidelines: Carlton County Median Family Income 5/1/2018 The available unit determines which Income Limit is used: 30%, 50%, 60% or 80% HOUSEHOLD SIZE AT OR BELOW THE LISTED % s 30% 50% 60% 80% Extremely Low Income Very Low Income Low Income 1 Person $15,000 $25,000 $30,000 $40,000 2 People $17,150 $28,600 $34,320 $45,700 3 People $20,780 $32,150 $38,580 $51,400 4 People $25,100 $35,700 $42,840 $57,100 5 People $29,420 $38,600 $46,320 $61,700 6 People $33,740 $41,450 $49,740 $66,250 (Income Limits are subject to change every year) 9
FOND DU LAC BAND OF LAKE SUPERIOR CHIPPEWA CONSENT TO CRIMINAL HISTORY INVESTIGATION FOR HOUSING SERVICES I, consent to allow the Fond du Lac Band of Lake Superior Chippewa to request and obtain information pertaining to my criminal history from any legally available sources for the purpose of verifying my eligibility for housing services from the Fond du Lac Band of Lake Superior Chippewa in Accordance with Fond du Lac Ordinance #02/09. This consent expires 15 months after signed. Every household member over 18 must fill out and sign a separate form. This form Must be legible and completed in its entirety. Date: Full Legal Name: (Last, First, Middle) Aliases: Date of Birth: Signature: DO NOT WRITE BELOW THIS LINE. OFFICE USE ONLY Housing Staff requesting background check: Teresa W. @ FDL Supportive Housing Initials of person who ran check: Date: Results: 10