FAMILY HEALTH GARDEN
HOUSING ASSISTANCE APPLICATION

Applicant Information:
- Full Name: ____________________
- Date of Birth: ________________
- Phone Number: ________________
- Email Address: ________________
- Current Address: _______________

Household Composition:
- Number of Adults: _____________
- Number of Children: ___________
- Ages of Children: _____________
- Household Income: _____________

Housing Situation:
□ At risk of eviction
□ Currently homeless
□ Unsafe housing conditions
□ Overcrowded housing
□ Need housing search assistance
□ Other: ______________________

Current Housing Status:
□ Renting
□ Own home
□ Staying with friends/family
□ Shelter
□ Other: ______________________

Monthly Housing Costs:
- Rent/Mortgage: _______________
- Utilities: ___________________
- Total: ______________________

Type of Assistance Needed:
□ Rental assistance
□ Security deposit
□ Moving expenses
□ Utility deposits
□ Housing search help
□ Landlord mediation

Amount of Assistance Requested: $______

Explanation of Housing Crisis:
_________________________________
_________________________________

Documentation Required:
□ Lease agreement
□ Eviction notice (if applicable)
□ Income verification
□ Utility bills
□ Identification

Signature: _____________________ Date: _________

Submit to: housing@familyhealthgarden.com
Call: (855) 937-9493