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Personal Information:

First Name

Last Name

Phone *

Date of birth

Email *

Preferred Language for Communication?

English
Spanish
French
Amharic
German
Chinese
Korean
Vietnamese
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Address

Street Address

City

State

Postal code

Total # of people in your household?

Self + 1
Self + 2
Self + 3
Self + 4
Self + 5
Self + 6
Self + 7
Self + 8
Self + 9
Self + 10 or more
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Do any household members have disabilities or special needs?

Yes

No

Please list the names, ages, and relationships of everyone living with you

John Doe / 12 / son

Housing Situation:

What is your current housing situation?

Renting

Living with Family

Shelter

Homeless

Other

How long have you been in your current housing situation?

3 - 6 Months
6 - 12 Months
1 - 2 Years
2 - 3 Years
3 - 5 Years
5+ Years
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Are you at risk of eviction or displacement?

Yes

No

Have you ever received housing assistance in the past? If so, from where?

Yes

No

If so, from where?

Employment Information:

Job Title:

Employer Name:

Length of Employment:

Annual Income:

Financial Information

What is your total monthly household income?

What are your main sources of income?

Employment
Child Support,
Benefits
Social Security Insurance (SSI)
Other
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Do you receive a housing voucher (e.g., Section 8, HCV)?

Yes

No

Support Needed

What type of support are you seeking? (check all that apply)

Emergency shelter

Temporary housing

Long-term housing

Financial assistance

Employment support

Food assistance

Credit Repair

Do you have any immediate safety concerns (e.g., domestic violence, unsafe conditions)?

What challenges or barriers have prevented you from securing stable housing?

Additional Information

Are you currently working with any other support organizations or case managers?

Yes

No

How did you hear about this organization?

Is there anything else you would like us to know to better understand your situation?

Preferred Contact Method:

Preferred Contact Method:

Phone
Email
SMS
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Restoring Homes, Empowering Lives

—that's what we do at Hamlin H.O.P.E.

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A 501(c)(3) Organization – Here for Our Community”

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1-888-435-1638