Nightshift manager

Maiker Housing Partners

Family Self-Sufficiency (FSS) Program Application

The FSS Program is open only to those who currently have a Maiker Housing Choice Voucher.

(This is not an application for Maiker housing)

Thank you for your interest i n Maiker Housing Partners’ FSS Program. All sections of this form must be completed for your application to be considered. You will be contacted by an FSS Coordinator when you are eligible to attend an FSSorientation or for an individual interview. Family Self-Sufficiency Program slots are limited, and completion of this form is not a guarantee of your acceptance into the program. For more information, please contact Elizabeth Aryeetey at 303-***-****.

Date:

Please check one:

I am a participant of the Maiker Housing Partners Housing Choice Voucher Program (Section 8)q

I receive assistance through the VASH ProgramqFUP ProgramqPBV Programq

Name:

Last 4 digits of SSN:

Address :

Apt./Unit:

City

Zip Code :

Home Phone:

I

Cell Phone

Best time to call

Email Address:

Be

Your Age:

q Male

qFemale st

Total in household under age 18

Total age 18 or older

ti

m

1. Are you currently employed?

e

qYes, Start Date / /

q No

Employer to

Job Title

Current total monthly income from employment

$

cal

l:

2. Do you or anyone in your household receive SSl /Social Security Disability

q Yes

q No

3. Is anyone in your household receiving cash assistance (TANF)?

4. Are you willing/ able to seek and maintain employment within the next 5 years?

q Yes

q No

q Yes

q No

5. Highest level of education completed?

6. If you were to enter the FSS Program, what are 2-3 goals that you would like to accomplish?

Return completed application by mail, e-mail, or fax to:

Fax: 720-***-**** Email: ***@********.***

FOR FSS OFFICE USE

Client T Code:

Recertification Month:

FSS Coordinator Approved

qYes

qNo

Specialist Approved qYes qNo

FSS Coordinator Initials:

Date:

Specialist Initials

Revised March 2020

Contact this candidate