Step 1 of 13

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*

Qualifying Disability and Homelessness Verification

Eden Village defines a chronically homeless person as – an unaccompanied unhoused person (a single unhoused person who is alone and is not part of an unhoused family and not accompanied by children) with the following:

Part 1: A Disabling Condition

Do you have any disabilities?*

Yes

What are you disabilities? Check all that apply.*

Alcohol Abuse

Alzheimer’s Disease/Dementia

Cognitive

Developmental

Drug Abuse

Hearing

HIV/AIDS

Learning

Mental Handicap/Injury

Mental Illness

Physical/Medical

Physical/Mobility

Visual

Speech

Other

Other disabilities*

What medical or mental diagnosis do you have?*

Are each of the disabilities listed above expected to be of a long, continued and indefinite duration and substantially impair your daily life?*

Yes

Which disabilities do not?*

Which of the above disabilities are you currently in treatment for?*

Part II – Duration in Tulsa Metro Area

Do you currently live in the Tulsa metropolitan area?*

Yes

How long have you lived in the Tulsa metropolitan area?*

Part III – Chronically Homelessness Status

Have you been continuously homeless for a year or more.*

HUD defines “homeless” as “a person sleeping in a place not meant for human habitation e.g. living on the streets for example OR living in a homeless emergency shelter.

Yes

Have you had four (4) episodes of homelessness in the last three (3) years.

HUD defines “homelessness” as “sleeping in a place not meant for human habitation e.g. living on the streets for example OR living in a homeless emergency shelter.

Yes

Part III is supported by obtaining Third Party Verification Letters, which verifies dates and locations of your homelessness. Third party verification is Eden Village’s preferred method of certifying chronic homelessness for the person applying for housing. The following are acceptable places that can provide verification of your homelessness. We accept Verification Letter(s) from: ● an emergency shelter for the unhoused person. ● an unhoused service provider or outreach worker. ● any other health or human service provider. ● Business owner ● Past Case Manager ● A fellow unhoused person ● Verification self-statement signed by the client.

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

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*

Do you currently have any legal charges pending or are you currently awaiting trial?*

Yes

Please explain about your legal charges*

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*

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

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.

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

Qualifying Disability and Homelessness Verification

Part 1: A Disabling Condition

Part II – Duration in Tulsa Metro Area

Part III – Chronically Homelessness Status

Income

Expenses

Employment

Medical

Criminal History

Educational Background

Additional Information

Emergency Contacts

Required Documents Upload

Statement of Independence