Government Housing Scheme Eligibility Assessment

Government Housing Scheme Eligibility Assessment
Please complete this form to help determine your eligibility for the government housing scheme. All information will be used solely for assessment purposes.
Full Name*
First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Current Residential Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*
MonthDayYear
Date

Household Members

Total Monthly Household Income (USD)*
RentingLiving with family/friendsHomelessOther
YesNo
YesNo
How long have you been residing in this city/region?*
How would you rate your current housing condition?*
Please provide any additional information that may support your eligibility (optional)
Should be Empty: