Transitional Housing Program Application

The Missoula YWCA is an Equal Opportunity/Employer agency. Auxiliary aids/services are available upon request for individuals with disabilities. For inquiries, write the Missoula YWCA at 1130 W. Broadway, Missoula, MT 59802, or call (406) 543-6691. Thank you for your interest in YWCA programs.

A United Way Agency

The YWCA Transitional Housing Program provides housing on a sliding fee scale, case management, life skills instruction, and support services. The YWCA Transitional Housing Program is committed to supporting homeless women and their children as they work towards self-sufficiency and independence. The program offers women the opportunity to gain knowledge, education, and skills in a variety of areas, while working on goals that will assist them in obtaining permanent housing and achieving economic security. The Transitional Housing Program is not a basic landlord-tenant relationship; it is an independent living self-sufficiency program.

Please complete the entire application. Completing this application does not guarantee that you will be accepted to the Transitional Housing Program. You will be contacted by telephone to set up a meeting with a staff person from the Transitional Housing Program. If you do not have a telephone number listed, you will be contacted through the mail. It is YOUR RESPONSIBILITY to alert us to any change in your contact information.

To be placed on the interview waiting list you will need to:

Attend the Transitional Housing Orientation on Wednesday mornings at 11AM at the YWCA
Bring in proof that you have signed up with the Missoula Housing Authority
Attend at least one life skills class offered by the YWCA

If you need assistance, please contact the Transitional Housing Manager as soon as possible at 543-6691, ext. 107.

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By completing the following application, you will provide information that will assist the YWCA in determining your eligibility.

Name __________________________________________________ Today’s Date _____________________

Mailing Address _______________________________________________________ Zip _________________

Phone _______________________ Other Contact/Message Numbers__________________________________

Birth date _______________________ City /County your original came to Missoula From _________________

*It is YOUR responsibility to alert us to any changes in your contact information *

General Information

How long have you lived in this community? _____________________
Who referred you to the YWCA? _______________________________
Are you a single head of household? Y N
Do you have any pets? Y N
If, so is it a service animal? Y N
Are you a veteran? Y N
Have you ever been arrested? Y N
If so, please give a brief explanation and the date of the arrest: ____________________________________________________________________________________________________________________________________________________________________________
Are you homeless or about to become homeless (can include living with a friend/family member)? Y N

If yes, how long have you been homeless? ________________________

10. Are you currently employed? Y N

Full time? _____Part time? _____

______________________________________________________________________________

Housing Status

1. Are you signed up with Missoula Housing Authority? Y N If YES, when did you turn in your application? _________________________

2. Have you signed up with other low income/subsidized housing agencies? Y N If YES, please list: ____________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________

3. Please describe your current living situation (where you are living, how long, circumstances that led up to you becoming/about to become homeless, etc.): _______________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family Size and Income

GROSS CASH INCOME RECEIVED BY EACH FAMILY MEMBER DURING THE LAST SIX MONTHS.

Please list all of the people living in your home during the past six months who are related by blood, marriage, or adoption and list all of your children whether or not they have been living with you (disregard income for those children that are not currently living with you). Include yourself.

Family Relationship	Full Name	Age	Monthly Income From All Sources	Source(s) of Income

Who from the list above will be living in the transitional housing apartment with you?

______________________________________________________________________________________

Is there anyone other than those listed above who will be staying with you? If so, how are you related?

__________________________________________________________________________________________________________________________________________________________________________________

If you have children please describe the custody/living arrangements (i.e., parenting plan/ visitation/arrangement?

Personal History/Information

1. Have you experienced violence in any form in the last two years? Y N

2. Do you currently feel safe? Y N If NO, please explains? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Reference Information

Please provide 3 references (examples: co-workers; family; friends; counselor; landlord; teacher; other non-profit organizations; case manager). **These references will only be checked after you are interviewed for the Transitional Housing Program.

Name: ___________________________________________ Phone: _________________________________

Address: ___________________________________________ City: ____________________ State: _______

How does this person know you? __________________________________ How long? ________________

Name: ___________________________________________ Phone: _________________________________

Address: ___________________________________________ City: ____________________ State: _______

How does this person know you? __________________________________ How long? ________________

Name: ___________________________________________ Phone: _________________________________

Address: ___________________________________________ City: ____________________ State: _______

How does this person know you? __________________________________ How long? ________________

Please provide one landlord reference:

Property Manager: ______________________________ Phone: __________________

Address: _____________________________________________ Apartment Number: ___________

City: ___________________________ State: ____________________

When did you rent from them? ___________________________________

Applicant Statement

My signature below certifies that all information on this application is true, correct, and complete to the best of my knowledge, and contains no willful falsifications or misrepresentations. I authorize the YWCA to contact my present and past employers and the references listed above to obtain information deemed appropriate to consider my application for the Transitional Housing program.

________________________________________________________________ ____________________

Applicant Signature Date