Temporary Housing Request

First and Last Name

Phone Number

Email Address

Date of Request

Family Information

How many individuals live within your residence?

Are their any kids that live with you?

yes

no

If yes, list kids' age and gender.

Describe any medical conditions of family members within residence.

Residence Information

Address of Home

Has your home been labeled as unlivable or condemned?

yes

no

Do you have insurance

yes

no

Please list the extent of damages to the residence.

Please list your current living situation

By signing this form, you understand that this is not a guarantee but a form for informational purposes only. Someone will be in contact about further steps if needed.

Signature