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Overflow Shared Housing Application

Full name as it appears on your ID

Social Security Number

Phone

Date of Birth

Gender

Marital Status

Never Married

Married

Divorced

Widowed

Separated

Current Living Situation

Do you have a vehicle?

Yes

What is the color, make and model?

Preferred Move-In Date*

Intended duration of stay:

Are you okay with a roommate? There are no bunk beds.

I need a private room

I’m okay with a shared room

I’m okay with either

Do you have a case manager or parole officer?

Yes

Please add the contact details for any agency personnel, case managers, or social workers you regularly work with. If none, write "None"*

Are you currently employed?

Part Time

Full Time

Student

Retired

If you are currently working, where are you employed?

Have you been in the military?

Yes

Are you eligible for veterans benefits?

Yes

Are you receiving or have you received services from? (Check all that apply)

Food Stamps

SSI

SSDI

General Gov Assistance

Vocational Rehabilitation

Medicaid

Medicare

What is your monthly income?

Are we expected to find any of the following in your background report?*

Felony

Misdemeanor

Traffic Violation

Other

Prefer Not to Disclose

None

Conviction of a crime will not result in automatic disqualification but lying will. Each case is reviewed on an individual basis, taking into account the nature of the offense, the severity, and the length of time since the offence was committed to ensure no dangerous persons are admitted entry into the residence. *By submitting this application you are consenting to a criminal background

Name of emergency contact and relation*

Emergency Contact Phone

Picture of government issued ID or DL

Signature*

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Please sign to the best of your ability.

Request an application

We kindly ask that application request be completed by referral source.

First name (referral source)*

Last name

Email*

Phone

Referral Source- Please include applicants first and last name along with a short description of his or her current living situation. Someone will be in touch soon.

OVERFLOW

Housing Solutions

For Questions

Call:

913-303-1318

Email:

overflowhelpforhumanity@gmail.com

We're currently accepting referrals from family members, medical professionals, pastors, case managers, and social workers. It's our joy to support you in finding safe, stable housing for someone you care about. We look forward to welcoming your friend or loved one home soon.