HomeShare Vermont Application

Please read through this entire application before you start so that you can gather the information you will need. If there is more than one adult applying to participate in the program, we will need information on that person as well. If you have any questions please feel free to call our office at (802) 863-5625.


Complete if you are seeking housing:

*Denotes required field

*First name: *Last name:

Other names used:

*Mailing address:

*City: *State: *Zip:

Physical address (if different):

Email:

Home phone:

Cell phone:

Work phone:

Best number to call during the day:


*How did you hear about HomeShare Vermont?

*Have you had any past association with HomeShare Vermont?  Yes No

Please be aware that there are typically 4 times the amount of people looking for housing as there are homes available and we cannot guarantee that everyone will find housing through our program.


*Number of people seeking housing together:

Date housing needed:

Please indicate your location preference:  Greater Burlington area Rural Chittenden County Addison County Grand Isle County Franklin County No preference

I will only consider these towns:

What is the maximum rent you would pay? $/month  Not sure

What is the maximum number of hours of service you can provide? hours/week  Not sure

What pets do you have?

If a dog, has it ever bitten anyone?

The following factors will help us better understand your housing needs. Please check the box if the statement applies to you.
 I have a car and can drive I can drive but don't have a car I need to be near a bus line I am a smoker


Housing history

*Current housing situation:

Explain:

*How long at current address? Since (mo/yr): /

Current Landlord's name:

Landlord's phone:

Previous housing situation:

Explain:

How long at this address (mo/yr)? / to /

Address City State

Previous landlord's name:

Landlord's phone:


For reporting and statistical purposes, our funders require that we ask for the following information.
This information will help determine that HomeShare Vermont does not discriminate in its services.

Gender:

*DOB M/D/Y: //

Age:

Ethnicity (check one):
 Hispanic Not Hispanic

Race (check all that apply):
 White Black/African American Asian American Indian/Alaskan Native Nat.Hawaiian/Other Pacific Islander Other Multiracial

Do you have a disability?  Yes No

*Do you receive Medicaid?  Yes No

*Annual gross income: (Must include all sources of income)


As part of our application process, we do background and reference checks and a personal interview.
To begin this process:

*Do you have any motor vehicle violations?  Yes No

*Do you have any pending criminal charges?  Yes No

*Have you had any criminal convictions?  Yes No

*Have you ever been evicted?  Yes No

If yes to any of these questions, please explain:


Employment history

*Current employment status:
 Full time Part time Retired Unemployed Student Other

Current employer:

Position/title:

City: State:

Date of hire (mo/yr): /

Previous employer: Status:  Part time Full time

Position/title:

Dates employed (mo/yr): / to /

City: State:


All references should be people who have known you at least 1 year. Together, the references should cover a span of at least 5 years to the present. We require references from past or present roommates, employers or co-workers. NOT ACCEPTED as references are family members, friends or romantic partners.

It is essential that you notify your references that HomeShare Vermont will be calling them. Please realize that if you have trouble reaching them, we will also have the same trouble, and your application will be delayed.

References

  1. *Reference 1 name:
    *Daytime phone:
    *City *State:
    Email:
    *How long have they known you?
    *How do they know you?
  2. *Reference 2 name:
    *Daytime phone:
    *City *State:
    Email:
    *How long have they known you?
    *How do they know you?
  3. *Reference 3 name:
    *Daytime phone:
    *City *State:
    Email:
    *How long have they known you?
    *How do they know you?
  4. *Reference 4 name:
    *Daytime phone:
    *City *State:
    Email:
    *How long have they known you?
    *How do they know you?

Other information you want us to know:


Is there another adult seeking housing with you?:

First name: Last name:

Other names used:

Mailing address:

City: State: Zip:

Physical address (if different):

Email:

Home phone:

Cell phone:

Work phone:

Best number to call during the day:


Housing history

Current housing situation:

If other, explain:

How long at current address? Since (mo/yr): /

Current Landlord's name:

Landlord's phone:

Previous housing situation:

If other, explain:

How long at this address (mo/yr)? / to /

Address City State

Previous landlord's name:

Landlord's phone:


For reporting and statistical purposes, our funders require that we ask for the following information.
This information will help determine that HomeShare Vermont does not discriminate in its services.

Gender:

DOB M/D/Y: //

Age:

Ethnicity (check one):
 Hispanic Not Hispanic

Race (check all that apply):
 White Black/African American Asian American Indian/Alaskan Native Nat.Hawaiian/Other Pacific Islander Other Multiracial

Do you have a disability?  Yes No

Do you receive Medicaid?  Yes No

Annual gross income: (Must include all sources of income)


As part of our application process, we do background and reference checks and a personal interview.
To begin this process:

Do you have any motor vehicle violations?  Yes No

Do you have any pending criminal charges?  Yes No

Have you had any criminal convictions?  Yes No

Have you ever been evicted?  Yes No

If yes to any of these questions, please explain:


Employment history

Current employment status:
 Full time Part time Retired Unemployed Student Other

Current employer:

Position/title:

City: State:

Date of hire (mo/yr): /

Previous employer: Status:  Part time Full time

Position/title:

Dates employed (mo/yr): / to /

City: State:


All references should be people who have known you at least 1 year. Together, the references should cover a span of at least 5 years to the present. We require references from past or present roommates, employers or co-workers. NOT ACCEPTED as references are family members, friends or romantic partners.

It is essential that you notify your references that HomeShare Vermont will be calling them. Please realize that if you have trouble reaching them, we will also have the same trouble, and your application will be delayed.

References

  1. Reference 1 name:
    Daytime phone:
    City State:
    Email:
    How long have they known you?
    How do they know you?
  2. Reference 2 name:
    Daytime phone:
    City State:
    Email:
    How long have they known you?
    How do they know you?
  3. Reference 3 name:
    Daytime phone:
    City State:
    Email:
    How long have they known you?
    How do they know you?
  4. Reference 4 name:
    Daytime phone:
    City State:
    Email:
    How long have they known you?
    How do they know you?

Other information you want us to know:

I hereby acknowledge that all the information I have given in this application is true and complete to the best of my knowledge and belief. I understand that providing any false or misleading information will make me ineligible for the services of HomeShare Vermont. I understand that, if I am matched, HomeShare Vermont will charge an income-based match fee at the time I move into the home.



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