Security Deposit Applications Housing Stability Security Deposit Assistance "*" indicates required fields Step 1 of 12 8% Household OverviewToday's Date* MM slash DD slash YYYY Anticipated Move-In Date (for Security Deposit only - if known) MM slash DD slash YYYY Head of Household Name* First Middle Last Date of Birth* MM slash DD slash YYYY Address*If no current address, type "0" or "N/A" in all fields. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone Number*Email Address* How did you hear about the Front Door Agency?*Local town/city welfare officeDepartment of Health and Human ServicesLocal school districtCommunity outreach workerCommunity non-profit211Previously received assistance from the Front Door AgencyMy own researchAre you applying for assistance as a result of the CoVid-19 pandemic?* Yes No If the applicant's primary language is not English and an interpreter is required, please list the primary language below: Describe the expenses and the amounts that are you seeking assistance with: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.NameRelationship to Head of HouseholdDate of Birth Add RemoveCurrent 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? Add RemoveCurrent 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?* Yes No If yes, state where and when. Is anyone in your household a domestic violence survivor or currently fleeing?* Yes No Has anyone in the household served in the US military?* Yes No If yes, who? Does anyone in the household have regular use of a vehicle?* Yes No Has anyone in the household has been diagnosed with a physical or mental health concern?* Yes No 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 Add RemoveBenefits*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 Add RemoveNon-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 Add RemoveAssets*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 Add Remove 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)* First Last SSN:* Date of Birth (Head of Household)* MM slash DD slash 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 IslanderWhiteOtherEthnicity (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 ProgramOtherWhat 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 CollegeOtherGED Earned? Yes No N/A Is Head of Household currently enrolled in school?* Yes No If yes, state the course and graduation date: Is Head of Household now, or have they ever been, in a job-training program?* Yes No 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?* Yes No 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) First Last Date of Birth (Household Member 2) MM slash DD slash 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 IslanderWhiteOtherEthnicity (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 ProgramOtherWhat 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 CollegeOtherIs Household Member 2 currently enrolled in school? Yes No If yes, state course and graduation date: Is Household Member 2 now, or have they ever been, in a job-training program? Yes No 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) First Last Date of Birth (Household Member 3) MM slash DD slash 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 IslanderWhiteOtherEthnicity (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 ProgramOtherWhat 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 CollegeOtherIs Household Member 3 currently enrolled in school? Yes No If yes, state course and graduation date: Is Household Member 3 now, or have they ever been, in a job-training program? Yes No 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) First Last Date of Birth (Household Member 4) MM slash DD slash 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 IslanderWhiteOtherEthnicity (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 ProgramOtherWhat 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 CollegeOtherIs Household Member 4 currently enrolled in school? Yes No If yes, state course and graduation date: Is Household Member 4 now, or have they ever been, in a job-training program? Yes No 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) First Last Date of Birth (Household Member 5) MM slash DD slash 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 IslanderWhiteOtherEthnicity (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 ProgramOtherWhat 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 CollegeOtherIs Household Member 5 currently enrolled in school? Yes No If yes, state course and graduation date: Is Household Member 5 now, or have they ever been, in a job-training program? Yes No 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/InternetOtherTOTAL MONTHLY HOUSING EXPENSES*This field will auto-calculate based on your entries above.Household ExpensesFoodToiletriesDiapers/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 typing my name and the date below, I hereby authorize the Front Door Agency staff to contact past and present landlords, employers, and creditors 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.*NameDatePlease click "Save and Continue Later" often so you do not lose your progress. Permission to Release Protected Health Information to the NH Homeless Service Provider NetworkReason for this Release: I would like to live in safe housing. I am signing this release to allow agencies in the NH Homeless Service Provider Network to talk about my needs and to share written and electronic information in order to help me find housing.* I understand and agree to the above statement. Right to Privacy: I have the right to keep information about my physical and mental health private. I understand that records about drug and alcohol use are protected by federal regulations and cannot be disclosed without my permission. I understand that I do not have to give permission to share my information, and that I will still receive services if I don’t give permission.* I understand and agree to the above statement. By signing this paper, I am giving permission to agencies in the NH Homeless Service Provider Network to share information about my physical and mental health. That information includes application forms, assessments, service plans, case notes, treatment records and records about drug and alcohol use.* I agree to share my information as detailed above. I do NOT agree to share my information as detailed above. Cancellation: I understand that I can cancel my permission at any time by telling any agency in the NH Homeless Service Provider Network. The cancellation stops future use of my information, but may not change actions that have already been taken.* I understand and agree to the above statement. Expiration: Unless I revoke my consent earlier, this consent will expire after 7 years.* I understand and agree to the above statement. By typing my name and today's date below, I declare that I have read the information on this page carefully and agree to allow the Front Door Agency to release my information as detailed above.*NameDateCommentsThis field is for validation purposes and should be left unchanged.
