Live-In Domestic Violence
Resume:
HOUSEHOLD INTAKE FORM PROGRAM:
Applicant Name: Assessment Date:
Phone(s): Cell: Home: Message:
E-mail Address: *required for PandaDoc
Residence (Physical) Address:
Street/Apt/Space# City/Zip
Mailing Address (if different):
Mailing address or PO Box City/Zip
Check box if same as physical address
Current Housing Status (see key on back page):
Literally Homeless
Housed and at imminent risk of losing housing
(within 14 days or less of eviction)
Housed and at risk of losing housing
(within 15-30 days of eviction)
Chronically Homeless (see definition – must be disabled) Household Type:
Single Individual Foster Parents
Single Parent Female Disabled w/ live-in aide
Single Parent Male Couple (no children)
Two Parent Family Co-habitants
Grandparent(s) & Child(ren) Unaccompanied Youth
Non-custodial Caregivers
Other
Domestic Violence Survivor HH? Yes No
Less than 3 months ago 3 to 6 months ago
6 to 12 months ago More than 1 year ago
If Homeless:
ORE-DAP HP
Angelina Johnson 04 / 27 / 2023
************@*****.***
2590 16th Ave SE Albany OR 97321
Document Ref: Q3KY8-NMSWA-U8PXA-MGZAW Page 1 of 6
Number of times homeless in past 3 years:
Number of months homeless in past 3 years:
Date became homeless:
Residence Status (Check one):
Own Subsidized Unit (Heat included)
Rent (Heat Included) Subsidized Unit (Heat not included) Rent (Heat not included) Not currently housed
Type of living situation on the night before program entry (i.e., last night): Emergency Shelter Psychiatric Hospital/Facility
Foster Care or Group Home Rental by Client, No subsidy Hospital (Non-Psychiatric) Transitional Housing for homeless Hotel/Motel - paid by client Rental by client, w/ GPD TIP subsidy Jail, Prison Or Juvenile Detention Rental by client w/other on-going subsidy Long-term care facility Residential project no homeless criteria Owned by Client, no Subsidy Safe Haven
Owned by client w/subsidy Staying/Living in Family's unit Permanent Housing for Homeless Staying/Living in Friend's unit Place not meant for habitation Substance Abuse Treatment Facility Rental by client w/ VASH
Length of stay:
One day or less
2-7 days
1-4 wks
1-3 months
3-12 months
1 yr or longer
01 / 21 / 2023
Document Ref: Q3KY8-NMSWA-U8PXA-MGZAW Page 2 of 6
Name of
Household
Member
Birth
Date
Age SSN Relation to
HoH
Gender Ethnic
Hispanic
/Latin
Y or N
Race US Veteran
Y or N
Member #1
Angelina Johnson
01/15/94
29
603743483
X- Self
F - Female
No
White
No
Member #2
Kayloni Parker 04/12/14 9-861******
D-Daughter F - Fem… No White No
Person 3
Willow Pulido
10/25/20
2
219957677
D-Daughter
F - Fem…
Yes
White
No
Person 4
Person 5
Person 6
Document Ref: Q3KY8-NMSWA-U8PXA-MGZAW Page 3 of 6
Household
Member
(continued
from above)
Education Health
Ins*
Disability Non-Cash Benefits RRH
VI-SPDAT
SCORE
HoH
Only
SNAP: Yes 197
Member #1
from above
10 - 10th … MC - … Disabled?
Long Duration?
Can live
independently?
N/A WIC
Childcare - TANF
Transportaton - TANF
Other TANF Funded Svc
Other non-TANF benefit
Member #2
from above
P - Presc… MC - … Disabled?
Long Duration?
Can live
independently?
N/A WIC
Childcare - TANF
Transportaton - TANF
Other TANF Funded Svc
Other non-TANF benefit
Person 3
from above
N - No Sc… MC - … Disabled?
Long Duration?
Can live
independently?
N/A
WIC
Childcare - TANF
Transportaton - TANF
Other TANF Funded Svc
Other non-TANF benefit
Person 4
from above
Disabled?
Long Duration?
Can live
independently?
WIC
Childcare - TANF
Transportaton - TANF
Other TANF Funded Svc
Other non-TANF benefit
Person 5
from above
Disabled?
Long Duration?
Can live
independently?
WIC
Childcare - TANF
Transportaton - TANF
Other TANF Funded Svc
Other non-TANF benefit
04 / 27 / 2023
* Health Ins: Do not use State Adults/Children
HOUSEHOLD INCOME AND ASSETS
Document Ref: Q3KY8-NMSWA-U8PXA-MGZAW Page 4 of 6
Adult #1 Name:
(First, Middle, Last, Suffix)
Does this person have Income from any source?
Yes No Don’t Know Refused
Income
Monthly Amount from Source
$ ZERO INCOME
$ Alimony / spousal support
$ Child Support
$ Private Disability Insurance
$ Pension from a former job
$ SSDI - Social Security Disability
$ SSI Supplemental Sec. Income
$ Social Security - Retirement
$ TANF
$ Veteran's Disability
$ Veteran's Pension
$ Unemployment
$ Self-employment
$ Wages / Earned Income
$ Workers Compensation
$ Other:
$ Total Monthly Income
Angelina Johnson
3274.69
3274.69
Adult #2 Name:
(First, Middle, Last, Suffix)
Does this person have Income from any source?
Yes No Don’t Know Refused
Income
Monthly Amount from Source
$ ZERO INCOME
$ Alimony / spousal support
$ Child Support
$ Private Disability Insurance
$ Pension from a former job
$ SSDI - Social Security Disability
$ SSI Supplemental Sec. Income
$ Social Security - Retirement
$ TANF
$ Veteran's Disability
$ Veteran's Pension
$ Unemployment
$ Self-employment
$ Wages / Earned Income
$ Workers Compensation
$ Other:
$ Total Monthly Income
ASSETS
$ Cash on Hand
$ Checking Account
$ Savings Account
$ Total Assets No Accounts
300.00
54.00
354.00
$ Cash on Hand
$ Checking Account
$ Savings Account
$ Total Assets No Accounts
Document Ref: Q3KY8-NMSWA-U8PXA-MGZAW Page 5 of 6
Does the household receive rental assistance
from any of the following programs?
Level of family income:
Section 8 Yes No
VASH Yes No
Public Housing Yes No
Area Med. Income:
=<30% 31-50% 51-80%
Poverty Level:
126-150%
Client signature affirming that the above information is correct. 04 / 27 / 2023
Document Ref: Q3KY8-NMSWA-U8PXA-MGZAW Page 6 of 6
Signature Certificate
Reference number: Q3KY8-NMSWA-U8PXA-MGZAW
Document completed by all parties on:
27 Apr 2023 22:38:18 UTC
Page 1 of 1
Signer Timestamp Signature
Angelina Johnson
Email: ************@*****.***
Recipient Verification:
Sent: 27 Apr 2023 22:36:35 UTC
Viewed: 27 Apr 2023 22:37:30 UTC
Signed: 27 Apr 2023 22:38:18 UTC
Email verified 27 Apr 2023 22:37:30 UTC
IP address: 174.204.197.88
Location: Portland, United States
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