Security Deposit Assistance Security Deposit Assistance Step 1 of 11 9% Household OverviewToday's Date* MM barra DD barra YYYY Anticipated Move-In Date (for Security Deposit Assistance Only - If Known) MM barra DD barra YYYY Head of Household Name* Primeiro Middle Último Date of Birth* MM barra DD barra YYYY Address*If no current address, type "0" or "N/A" in all fields. Endereço da rua Address Line 2 Cidade Estado / Província / Região CEP / Código Postal País AfeganistãoAlbâniaArgéliaSamoa AmericanaAndorraAngolaAnguillaAntárticaAntígua e BarbudaArgentinaArmêniaArubaAustráliaÁustriaAzerbaijãoBahamasBahreinBangladeshBarbadosBelarusBélgicaBelizeBeninBermudasButãoBolíviaBonaire, Santo Eustáquio e SabaBósnia e HerzegovinaBotsuanaIlha BouvetBrasilTerritório Britânico do Oceano ÍndicoBrunei DarussalamBulgáriaBurkina FasoBurundiCabo VerdeCambojaCamarõesCanadáIlhas CaymanRepública Centro-AfricanaChadeChileChinaIlha do NatalIlhas CocosColômbiaComoresCongoCongo, República Democrática doIlhas CookCosta RicaCroáciaCubaCuraçaoChipreRepública TchecaCosta do MarfimDinamarcaDjibutiDominicaRepública DominicanaEquadorEgitoEl SalvadorGuiné EquatorialEritreiaEstôniaEswatiniEtiópiaIlhas FalklandIlhas FaroeFijiFinlândiaFrançaGuiana FrancesaPolinésia FrancesaTerritórios Franceses do SulGabãoGâmbiaGeórgiaAlemanhaGanaGibraltarGréciaGroenlândiaGranadaGuadalupeGuamGuatemalaGuernseyGuinéGuiné-BissauGuianaHaitiIlha Heard e Ilhas McDonaldSanta SéHondurasHong KongHungriaIslândiaÍndiaIndonésiaIrãIraqueIrlandaIlha de ManIsraelItáliaJamaicaJapãoJerseyJordâniaCazaquistãoQuêniaKiribatiCoreia, República Popular Democrática daCoreia, República daKuwaitQuirguistãoRepública Democrática Popular do LaosLetôniaLíbanoLesotoLibériaLíbiaLiechtensteinLituâniaLuxemburgoMacauMadagascarMalawiMalásiaMaldivasMaliMaltaIlhas MarshallMartinicaMauritâniaIlhas MaurícioMayotteMéxicoMicronésiaMoldáviaMônacoMongóliaMontenegroMontserratMarrocosMoçambiqueMyanmarNamíbiaNauruNepalPaíses BaixosNova CaledôniaNova ZelândiaNicaráguaNígerNigériaNiueIlha NorfolkMacedônia do NorteIlhas Marianas do NorteNoruegaOmãPaquistãoPalauPalestina, Estado daPanamáPapua Nova GuinéParaguaiPeruFilipinasPitcairnPolôniaPortugalPorto RicoQatarRomêniaFederação RussaRuandaReuniãoSão BartolomeuSanta Helena, Ascensão e Tristão da CunhaSão Cristóvão e NévisSanta LúciaSão MartinhoSão Pedro e MiquelonSão Vicente e GranadinasSamoaSão MarinoSão Tomé e PríncipeArábia SauditaSenegalSérviaSeychellesSerra LeoaCingapuraSão MartinhoEslováquiaEslovêniaIlhas SalomãoSomáliaÁfrica do SulIlhas Geórgia do Sul e Sandwich do SulSudão do SulEspanhaSri LankaSudãoSurinameSvalbard e Jan MayenSuéciaSuíçaRepública Árabe da SíriaTaiwanTajiquistãoTanzânia, República Unida daTailândiaTimor-LesteTogoTokelauTongaTrinidad e TobagoTunísiaTurcomenistãoIlhas Turcas e CaicosTuvaluTurquiaIlhas Menores Distantes dos EUAUgandaUcrâniaEmirados Árabes UnidosReino UnidoEstados UnidosUruguaiUzbequistãoVanuatuVenezuelaVietnãIlhas Virgens BritânicasIlhas Virgens, EUAWallis e FutunaSaara OcidentalIêmenZâmbiaZimbábueIlhas Åland Número de telefone*Endereço de e-mail* Enter Email Confirm Email What pronouns do you associate with?*He/HimShe/HerThey/ThemIf the applicant's primary language is not English and an interpreter is required, please list the primary language below: How did you hear about the Front Door Agency?*Local town/city welfareDepartment of Health and Human ServicesLocal school districtCommunity outreach workerCommunity non-profit211Previously received assistance from the Front Door AgencyMy own researchWhat currently brings you joy in your life?* Describe the expenses and the amounts that are you seeking assistance with:What is the total amount requested?* Briefly describe the circumstances that led to an inability to meet these expenses:Briefly describe how you will be able to maintain your housing after receiving assistance from FDA:List any other organizations that you have received financial assistance from in the past 12 months: Household Members*Please list every person that lives in your household. You will be asked more information about each of these individuals on the next page of this application. Click "+" to add a new row.NomeRelationship to Head of HouseholdEmail Address (for adult household members only) Date of birth MM barra DD barra YYYY Current Residence- where did you stay last night?*Rental by applicant, no ongoing housing subsidy, pay full rent myselfRental by applicant, with housing subsidy- receive Section 8, public housing, or in an affordable rent programOwned by applicantTransitional housing for homeless persons (including homeless youth)Permanent housing for formerly homeless personsStaying or living in family member’s room, apartment, or houseHotel or motel paid for directly by me (without emergency shelter voucher or assistance)Sober living facilityEmergency shelter, inc. hotel/motel with emergency shelter voucherHomeless- in a place not meant for habitationIf applicable, how long have you been without permanent housing? Residence History (click "+" to add a new row for each previous address)*Provide your residence history, listing most recent first and including any amounts owed. Click "+" to add a new row.Dates from and to (list most recent first)AddressHousing TypeMonthly RentDo you owe past due rent? Amount?Do you owe past due utilities? Amount?Reason left? Current Landlord Name*Write "N/A" if not applicable. Current Landlord Phone NumberCurrent Landlord Email Address For any previous evictions, provide dates and briefly describe grounds for eviction: Type N/A if not applicable*If applicant receives a Section 8, other housing voucher or subsidized housing, please describe: Have you have applied for Section 8 or other Subsidized Housing?* Sim Não If yes, state where and when. Is anyone in your household a domestic violence survivor or currently fleeing?* Sim Não Has anyone in the household served in the US military?* Sim Não If yes, who? Does anyone in the household have regular use of a vehicle?* Sim Não Has anyone in the household has been diagnosed with a physical or mental health concern?* Sim Não If yes, state who and the diagnosis. Income and AssetsList ANY income from ALL household members received within the last 3 months as indicated.Employment*Start with most recent. Click "+" to add a new row. If none, type "N/A."Household Member's NameEmployerPositionWage ($/hr)# Hours/weekStart/End Dates Benefits*List ALL cash benefits and/or other income received by EACH household members in the past 30 days. Click "+" to add a new row. If none, type "N/A."Household Member's NameBenefit/IncomeAmountFrequency Non-Cash Benefits*List ANY other assistance received by EACH household member in the past 30 days (childcare, Food Stamps, Fuel Assistance etc). Click "+" to add a new row. If none, type "N/A."Household Member's NameBenefit/IncomeAmountFrequency Assets*List the value of any liquid assets for all household members as of date of application. Click "+" to add a new row. Type "N/A" if none.Source of Asset (i.e., savings, stocks, etc.)Current ValueLess Withdrawal PenaltyTotal Net Value Household Composition - PLEASE READ!The next 5 pages of the application are for you to provide information about each member of your household. The first page is for the Head of Household, the next page is for Household Member 2, then Household Member 3, etc. If you do not have 5 people living in your household, please skip the pages you do not need. If you have more than 5 people living in your household, please email dhoward@frontdooragency.org. Information for Head of HouseholdName (Head of Household)* Primeiro Último SSN:* Date of Birth (Head of Household)* MM barra DD barra YYYY Relationship to Head of Household*SelfCo-head of Household, Spouse or Significant OtherChild (daughter)Child (son)Foster ChildOther ChildFatherMotherOther Adult (not a relative)Other Adult Relative (aunt, grandparent, cousin, etc.)Race (Head of Household)*Choose as many as apply. Hold down "Ctrl" and click to select more than one option. American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOutrosEthnicity (Head of Household)* Hispanic Non-Hispanic Gender (Head of Household)* Male Female Transgender female to male Transgender male to female Gender Non-conforming (not exclusively male or female) Marital Status (Head of Household)* Single Married Divorced Separated Widowed Living Together N/a What type of health insurance does Head of Household have?*Choose as many as apply. Hold down "Ctrl" and click to select more than one option. NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOutrosWhat Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy FamiliesWhat is the highest level of education that Head of Household has earned?*Did Not Finish High SchoolHigh School or GEDAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOutrosGED Earned? Sim Não N/A Is Head of Household currently enrolled in school?* Sim Não If yes, state the course and graduation date: Is Head of Household now, or have they ever been, in a job-training program?* Sim Não If yes, where and what type of program? Employment Status (Head of Household)* Full time Part time Unemployed < 6 months Unemployed >6 months Not in work force Does Head of Household require assistance with reading or writing?* Sim Não Please click "Save and Continue Later" often so you do not lose your progress. Information for Household Member 2If you do not have a 2nd member of your household, please skip this page.Name (Household Member 2) Primeiro Último Date of Birth (Household Member 2) MM barra DD barra YYYY Relationship to Head of HouseholdSelfCo-head of Household, Spouse or Significant OtherChild (daughter)Child (son)Foster ChildOther ChildFatherMotherOther Adult (not a relative)Other Adult Relative (aunt, grandparent, cousin, etc.)Race (Household Member 2)Choose as many as apply. Hold down "Ctrl" and click to select more than one option. American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOutrosEthnicity (Household Member 2) Hispanic Non-Hispanic Gender (Household Member 2) Male Female Transgender female to male Transgender male to female Gender Non-conforming (not exclusively male or female) Marital Status (Household Member 2) Single Married Divorced Separated Widowed Living Together N/a What type of health insurance does Household Member 2 have?Choose as many as apply. Hold down "Ctrl" and click to select more than one option. NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOutrosWhat Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy FamiliesWhat is the highest level of education that Household Member 2 has earned?Did Not Finish High SchoolHigh School or GEDAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOutrosIs Household Member 2 currently enrolled in school? Sim Não If yes, state course and graduation date: Is Household Member 2 now, or have they ever been, in a job-training program? Sim Não If yes, where and what type of program? Employment Status Full time Part time Unemployed < 6 months Unemployed >6 months Not in work force Please click "Save and Continue Later" often so you do not lose your progress. Information for Household Member 3If you do not have a 3rd member of your household, please skip this page.Name (Household Member 3) Primeiro Último Date of Birth (Household Member 3) MM barra DD barra YYYY Relationship to Head of HouseholdSelfCo-head of Household, Spouse or Significant OtherChild (daughter)Child (son)Foster ChildOther ChildFatherMotherOther Adult (not a relative)Other Adult Relative (aunt, grandparent, cousin, etc.)Race (Household Member 3)Choose as many as apply. Hold down "Ctrl" and click to select more than one option. American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOutrosEthnicity (Household Member 3) Hispanic Non-Hispanic Gender (Household Member 3) Male Female Transgender female to male Transgender male to female Gender Non-conforming (not exclusively male or female) Marital Status (Household Member 3) Single Married Divorced Separated Widowed Living Together N/a What type of health insurance does Household Member 3 have?Choose as many as apply. Hold down "Ctrl" and click to select more than one option. NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOutrosWhat Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy FamiliesWhat is the highest level of education that Household Member 3 has earned?Did Not Finish High SchoolHigh School or GEDAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOutrosIs Household Member 3 currently enrolled in school? Sim Não If yes, state course and graduation date: Is Household Member 3 now, or have they ever been, in a job-training program? Sim Não If yes, where and what type of program? Employment Status Full time Part time Unemployed < 6 months Unemployed >6 months Not in work force Please click "Save and Continue Later" often so you do not lose your progress. Information for Household Member 4If you do not have a 4th member of your household, please skip this page.Name (Household Member 4) Primeiro Último Date of Birth (Household Member 4) MM barra DD barra YYYY Relationship to Head of HouseholdSelfCo-head of Household, Spouse or Significant OtherChild (daughter)Child (son)Foster ChildOther ChildFatherMotherOther Adult (not a relative)Other Adult Relative (aunt, grandparent, cousin, etc.)Race (Household Member 4)Choose as many as apply. Hold down "Ctrl" and click to select more than one option. American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOutrosEthnicity (Household Member 4) Hispanic Non-Hispanic Gender (Household Member 4) Male Female Transgender female to male Transgender male to female Gender Non-conforming (not exclusively male or female) Marital Status (Household Member 4) Single Married Divorced Separated Widowed Living Together N/a What type of health insurance does Household Member 4 have?Choose as many as apply. Hold down "Ctrl" and click to select more than one option. NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOutrosWhat Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy FamiliesWhat is the highest level of education that Household Member 4 has earned?Did Not Finish High SchoolHigh School or GEDAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOutrosIs Household Member 4 currently enrolled in school? Sim Não If yes, state course and graduation date: Is Household Member 4 now, or have they ever been, in a job-training program? Sim Não If yes, where and what type of program? Employment Status Full time Part time Unemployed < 6 months Unemployed >6 months Not in work force Please click "Save and Continue Later" often so you do not lose your progress. Information for Household Member 5If you do not have a 5th member of your household, please skip this page.Name (Household Member 5) Primeiro Último Date of Birth (Household Member 5) MM barra DD barra YYYY Relationship to Head of HouseholdSelfCo-head of Household, Spouse or Significant OtherChild (daughter)Child (son)Foster ChildOther ChildFatherMotherOther Adult (not a relative)Other Adult Relative (aunt, grandparent, cousin, etc.)Race (Household Member 5)Choose as many as apply. Hold down "Ctrl" and click to select more than one option. American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOutrosEthnicity (Household Member 5) Hispanic Non-Hispanic Gender (Household Member 5) Male Female Transgender female to male Transgender male to female Gender Non-conforming (not exclusively male or female) Marital Status (Household Member 5) Single Married Divorced Separated Widowed Living Together N/a What type of health insurance does Household Member 5 have?Choose as many as apply. Hold down "Ctrl" and click to select more than one option. NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOutrosWhat Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy FamiliesWhat is the highest level of education that Household Member 5 has earned?Did Not Finish High SchoolHigh School or GEDAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOutrosIs Household Member 5 currently enrolled in school? Sim Não If yes, state course and graduation date: Is Household Member 5 now, or have they ever been, in a job-training program? Sim Não If yes, where and what type of program? Employment Status Full time Part time Unemployed < 6 months Unemployed >6 months Not in work force Please click "Save and Continue Later" often so you do not lose your progress. Monthly Household IncomeComplete this page to the best of your ability, using MONTHLY amounts. False information will result in dismissal from this program.SalarySSDITANFSocial Security IncomeWorker's CompUnemploymentChild SupportAlimonyElderly AssistancePensionAPTDFood Stamps Other Income AmountTOTAL HOUSEHOLD MONTHLY INCOME*This field will auto-calculate based on your entries above. Food Stamps and Section 8/Rent Vouchers are not included in this total.Please click "Save and Continue Later" often so you do not lose your progress. Monthly Housing ExpensesProof of all expenses must be provided at the time of appointment. Please include EVERYTHING you spend money on each month, including but not limited to; food, phone service, cable and internet, laundry, car payments, insurance, medications, loans, credit cards, recreation, etc. Use MONTHLY totals.Rent/Mortgage PaidElectricityGasPhone BillCable/InternetOutrosTOTAL MONTHLY HOUSING EXPENSES*This field will auto-calculate based on your entries above.Household ExpensesFoodProdutos de higiene pessoalDiapers/WipesLaundryPet FoodOther ExpenseTOTAL MONTHLY HOUSEHOLD EXPENSES*This field will auto-calculate based on your entries above.Monthly Transportation ExpensesCar PaymentGasolineCar InsuranceMaintenanceBus/Cab/UberOther ExpenseTOTAL MONTHLY TRANSPORTATION EXPENSES*This field will auto-calculate based on your entries above.Personal/Other Monthly ExpensesCredit Card PaymentsRent-to-OwnLoansChild SupportMedications & VitaminsChildcareHair & NailsDonationsCigarettesSchool LunchesSports/RecreationOther ExpensesTOTAL PERSONAL/OTHER MONTHLY EXPENSES*This field will auto-calculate based on your entries above.Total Household Monthly ExpensesTotal Household Monthly Expenses*This field will auto-calculate based on your entries above.Total Monthly Disposable IncomeTotal Monthly Income - Total Monthly ExpensesTotal Monthly Disposable Income*This field will auto-calculate based on your entries for total income and total expenses.Please click "Save and Continue Later" often so you do not lose your progress. Release of InformationBy signing and dating below, I hereby authorize The Front Door Agency staff to contact past and present landlords and utility companies for the purpose of verifying information for my application for assistance, as well as any city, state or federal agencies that are providing me or anyone in my household with assistance.Head of Houshold Signature:*Date* MM barra DD barra YYYY Co-Applicant SignatureDate* MM barra DD barra YYYY Please click "Save and Continue Later" often so you do not lose your progress.NomeEsse campo é para fins de validação e deve ser deixado inalterado.