Page 1

PROGRAM OVERVIEW

Family Promise’s transitional housing program serves low-income families with children.

Families in the transitional housing program receive comprehensive support services to help ensure their success, including Intensive Case Management and Life Skills Training.

PROGRAM OVERVIEW

Your family must be homeless or near homelessness at the time of application.
Your family must have at least one child under the age of 18 living with you.
Your family must be able to live in a 2- or 3-bedroom apartment.
Your family must have a prearranged payment plan designed to repay any outstanding debts to PECO.
Your family must be experiencing a situation where significant progress or resolution is possible within a 1-year period.
You must have a willingness to set and work toward goals.
Your family income must be at or below 50% Area Median Income for Montgomery County. Use the chart provided below to calculate AMI percentage for your household size.
Head of household must be employed at least 30 hours/weekly.

My family meets all the criteria listed above to qualify to apply to the program.

YesNo

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Thank you for taking the time to provide us with your information and express your interest in our transitional housing program.

Based on the information you have provided and the current criteria of the program, you are not eligible for our transitional housing program at this time.

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HOUSEHOLD INFORMATION

Head of Household Information

Your first name

Your last name

Your email

Your phone number

City

State

Date of birth (MM/DD/YYYY)

Are you already working with a case manager?

YesNo

Case manager name

Case manager phone number

Are there other agencies providing services to your family?

YesNo

If yes, please describe

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ADDITIONAL HOUSEHOLD INFORMATION

Household Member 2 Information

Household member 2 first name

Household member 2 last name

Household member 2 relationship to head of household

Household member 2 date of birth (MM/DD/YYYY)

Add a third household member?

YesNo

Household Member 3 Information

Household member 3 first name

Household member 3 last name

Household member 3 relationship to head of household

Household member 3 date of birth (MM/DD/YYYY)

Add a fourth household member?

YesNo

Household Member 4 Information

Household member 4 first name

Household member 4 last name

Household member 4 relationship to head of household

Household member 4 date of birth (MM/DD/YYYY)

Add a fifth household member?

YesNo

Household Member 5 Information

Household member 5 first name

Household member 5 last name

Household member 5 relationship to head of household

Household member 5 date of birth (MM/DD/YYYY)

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PRIOR HOUSING INFORMATION

Briefly describe the circumstances that led to losing your housing.

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INCOME INFORMATION

Please list ALL sources of income below. Report gross (before tax) monthly amounts.

Do not use dollar signs in amount fields.

Income from Employment

Job 1 employee name (enter NA if not applicable)

Job 1 gross monthly wages (enter 0 if not applicable; do not use dollar sign)

Job 2 employee name (enter NA if not applicable)

Job 2 gross monthly wages (enter 0 if not applicable)

Income from Social Security (SSI, SSDI)

Recipient 1 name (enter NA if not applicable)

Recipient 1 monthly amount (enter 0 if not applicable)

Recipient 2 name (enter NA if not applicable)

Recipient 2 monthly amount (enter 0 if not applicable)

Recipient 3 name (enter NA if not applicable)

Recipient 3 monthly amount (enter 0 if not applicable)

Income from Public Assistance