Step 1 of 14

Have you completed the Qualifying Disability and Homelessness Verification form?*

Yes

The first step is to ensure you qualify before completing the application process. Please complete the Qualifying Disability and Homelessness Verification form before proceeding with this application.

Complete Legal Name*

First Middle Last

Nickname (or other names used)

Date of Birth*

Month

Day

Year

Place of Birth*

Social Security #*

Driver's License/State ID #

State of Issuance

Cell Phone

Work Phone

Do you currently have a case manager?*

Yes

Case Manager Name*

Agency*

Case Manager Phone*

Income

List all sources of income and expenses. Sources of income must be verifiable. Please attach copies of documentation (i.e. pay stubs) that will assist us in verifying a stable source of income.

Earned Income (Job)

Unemployment Insurance

Supplemental Security Insurance (551)

Social Security Disability Insurance (5501)

VA (Service Connected Disability)

VA (Non-service Connected Disability)

Private Disability Insurance

Worker's Compensation

General Assistance

Social Security Retirement

Pension/Retirement from Job

Child Support

Alimony/Spousal Support

SNAP (Food Stamps)

WIC

Section 8/Public Housing/Rental Assistance

Temporary Assistance

Other

Total Income

Expenses

Phone

Car Payment/Insurance/Maintenance

Food

Transportation/Gasoline

Medical (Dr, prescriptions, etc.)

Other

Total Expenses

Employment

Are you currently employed?*

Yes

Employer*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Employment Status*

Full Time

Part Time

Temporary

When Did You Start This Job?*

Month

Day

Year

Medical

Are you currently covered by health insurance?*

Yes

Program*

You are required to attach a copy of your health insurance card. This application is not complete without proper documentation of health insurance.

Do you have a primary care provider?*

Yes

Provider Name and Location*

Do you have a mental healthcare provider?*

Yes

Provider Name and Location*

Are you a victim or survivor of domestic violence?*

Yes

When did this occur and by whom?*

Do you have a medical marijuana license or do you take any controlled substances that are prescribed to you?*

Yes

Do you currently have any drug or alcohol addiction issues?*

Yes

Are you willing to submit to a drug test?*

Yes

Do you smoke?*

Yes

Have you had an incident of bed bugs in the last 12 months?*

Yes

Do you have any of the following End of Life Documents? Check all that apply.

Declaration of Guardian

Directive to Physicians

Durable Power of Attorney

HIPAA Release

Death Certificate Information Sheet

Criminal History

Have you ever been convicted of a felony?*

Yes

Please explain about your felony conviction*

Are you currently on probation?*

Yes

Are you a registered sex offender?*

Yes

Do you currently have any outstanding warrants for your arrest?*

Yes

Please explain about the warrants*

Have you ever been arrested and/or convicted of domestic violence?*

Yes

Please explain about your arrest or conviction*

Educational Background

Highest Level of Education Completed*

Do you have difficulty with reading or writing?*

Yes

Please explain your difficulty*

Have you ever served in the military?*

Yes

Branch*

Veteran Status*

Do you have a copy of your DD-214?*

Yes

Additional Information

Do you have children that are minors?*

Yes

Do you own any animals?*

Yes

Type of Animal*

Breed*

Approximate Weight*

Do you own a car that will be parked on the property?*

Yes

You are required to show proof that your car’s registration is up-to date. Please note that vehicles are prohibited from parking on the premises if they are inoperable, have no license plate, no current registration, or no current registration sticker. This application is not complete without attached proper documentation for any cars you own.

Have you ever been evicted from housing in the past?*

Yes

Please explain more about your eviction*

References

List 3 people who are NOT family members and can serve as a personal reference.

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Reference 2

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Reference 3

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contacts

List 3 people to contact in case of an emergency.

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Contact #2

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Contact #3

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Favorites

As a neighbor of Eden Village we want to get to know you better! Please let us know some fun facts about yourself.

What are your favorite sports teams?

What is your favorite hobbies or skills?

What are your favorite foods?

What type of music do you like?

Like to read? What books?

What is your favorite holiday?

What do you dream of being able to do?

Where do you see yourself in 5 years?

Required Documents Upload

Photo ID*

Accepted file types: jpg, png, gif, pdf, Max. file size: 64 MB.

Drivers License or State ID.

Income Verification Documents*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Upload a copy of any proof of income that you receive. This can be a pay stub or monthly statement.

Proof of Insurance*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Upload a copy of your insurance card or other documentation.

Vehicle Documentation*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Upload a copy of your vehicle registration for each vehicle you own.

Pet Documentation

Drop files here or

Accepted file types: job, gif, png, pdf, Max. file size: 64 MB.

You stated that you have a pet. If you have any documentation such as shot records or license please upload it here.

Statement of Independence

Eden Village of Tulsa is a 501(c)(3) non-profit organization and is designed to provide independent, affordable, sustainable housing with dignity to those who are experiencing chronic homelessness. Chronic homelessness is defined as being continuously homeless for one year or more or being homeless at least four times for long durations over the past three years or living in a place not meant for human habitation. It is the expectation that all applicants will be able to live independently as single occupants in a home in a community environment. The occupant(s) will be expected to maintain a clean and orderly home. Eden Village staff will make random and periodic inspections to ensure the home is kept in an orderly fashion. Eden Village does not provide case management services or counseling. (Medical or psychiatric care, house cleaning, transportation, etc.) Most of the services that an applicant may need will be obtained from outside sources and made available in the Eden Village’s Community Center. Eden Village and applicant(s) acknowledge that it is very difficult to live on a limited income. It will be important for the applicant(s) to understand what other services are available in the city that would help offset the cost of everyday living.

Certification*

I agree

By signing this document with my digital signature, I attest that I am financially, physically and emotionally fit to live independently as set out above. All information provided is true and accurate. I understand that any inaccuracy or incomplete information provided could cause my application to be rejected.

Certification*

I agree

By signing this document with my digital signature I certify that the information presented in this application is true to the best of my knowledge. I understand that false or misleading information may result in termination of housing.

Digital Signature*

Resident Application

Income

Expenses

Employment

Medical

Criminal History

Educational Background

Additional Information

References

Emergency Contacts

Favorites

Required Documents Upload

Statement of Independence