Momentum Dwellings

Application Form

Our shared housing includes:

Furnished bedrooms
Furnished common areas
Fully equipped Kitchen
High Speed Internet
Utilities
On-site washer and dryer

Members also:

Must be able to live independently
Must understand that common spaces are shared with other guests in the home
Must be at least 18 years of age
Must have income to cover rent and basic needs
Must adhere to house rules

This form helps us review applications for housing at Momentum Dwellings. Please answer honestly. All information is kept private. Momentum Dwellings reserves full discretion in all housing decisions. Decisions are made in accordance with Fair Housing laws.If you have any questions, please reach out to info@momentumdwellings.org

Personal Information

First name:

MI:

Last name:

Phone:

Email:

Date of Birth:

Month

Day

Year

SSN / ITIN:

Gender:

Male

Female

Other

Government ID

Drivers License

State ID

Passport

Upload ID

Upload your file

Choose a file or drag and drop one here.

Why are you seeking housing with Momentum Dwellings?

Health & Accessibility

Are you able to live independently and handle daily tasks on your own?

Yes

Do you need any accommodations to live safely and comfortably in shared housing?

Yes

Do you have any mental health diagnoses?

Yes

Income & Financials

How much money do you make every month?

Please Upload Proof of Income (Pay stubs, Bank Statements, Award Letter, etc.)

Upload your file

Choose a file or drag and drop one here.

Do you have the first month’s rent and move-in fee available today?

Yes

Background

Have you been in jail or prison within the last 5 years?

Yes

Are you currently on probation or parole?

Yes

Are you a registered sex offender?

Yes

Emergency Contact

First Name

Last Name

Relationship

Phone Number

House Rules & Agreement

This is a community living situation in a home with multiple people. We don't have individual apartments. Are you okay living in a group situation?

Yes

This is a program, not a lease. You could be removed immediately for breaking the rules of the house or causing disturbances. Please acknowledge that you understand this.

Yes

All of our houses are sober environments. Alcohol, marijuana, and illegal substances are not allowed on the property, and anyone caught with them will be immediately removed. Please acknowledge that you understand this.

Yes

Are you a minor or have minors with you? We currently only house adults.

Yes

Do you have a pet or a service? Note: We currently can not accommodate animals.

Yes

Consents

I authorize Momentum Dwellings to:

1. Run background, criminal, eviction, and credit checks;

2. Verify income, housing history, rental assistance, and references;

3. Contact my payee, case manager, employer, or emergency contact if needed.

I release Momentum Dwellings, its staff, my case manager, and listed references from any liability related to the sharing or verification of information for this application.

I understand that providing false or incomplete information may result in denial or removal from housing.

Signature

Please Type Your Full Legal Name

Today's Date

Momentum Dwellings

Application Form

Our shared housing includes:

Furnished bedrooms
Furnished common areas
Fully equipped Kitchen
High Speed Internet
Utilities
On-site washer and dryer

Members also:

Must be able to live independently
Must understand that common spaces are shared with other guests in the home
Must be at least 18 years of age
Must have income to cover rent and basic needs
Must adhere to house rules

Personal Information

First name:

MI:

Last name:

Date of Birth:

Month

Day

Year

Gender:

Male

Female

Other

Government ID

Drivers License

State ID

Passport

Upload ID

Upload your file

Choose a file or drag and drop one here.

Why are you seeking housing with Momentum Dwellings?

Health & Accessibility

Are you able to live independently and handle daily tasks on your own?

Yes

Do you need any accommodations to live safely and comfortably in shared housing?

Yes

Do you have any mental health diagnoses?

Yes

Income & Financials

How much money do you make every month?

Please Upload Proof of Income (Pay stubs, Bank Statements, Award Letter, etc.)

Upload your file

Choose a file or drag and drop one here.

Do you have the first month’s rent and move-in fee available today?

Yes

Have you been in jail or prison within the last 5 years?

Yes

Are you currently on probation or parole?

Yes

Are you a registered sex offender?

Yes

Emergency Contact

First Name

Last Name

House Rules & Agreement

This is a community living situation in a home with multiple people. We don't have individual apartments. Are you okay living in a group situation?

Yes

This is a program, not a lease. You could be removed immediately for breaking the rules of the house or causing disturbances. Please acknowledge that you understand this.

Yes

Are you a minor or have minors with you? We currently only house adults.

Yes

Do you have a pet or a service? Note: We currently can not accommodate animals.

Yes

I authorize Momentum Dwellings to:

1. Run background, criminal, eviction, and credit checks;

2. Verify income, housing history, rental assistance, and references;

3. Contact my payee, case manager, employer, or emergency contact if needed.

I release Momentum Dwellings, its staff, my case manager, and listed references from any liability related to the sharing or verification of information for this application.

I understand that providing false or incomplete information may result in denial or removal from housing.

Please Type Your Full Legal Name