Beyond Housing Senior Living

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Name*

First Last

Date of Birth: must be 55 years of age or older!*

MM slash DD slash YYYY

Home Phone*

Work Phone

Cell Phone

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you From St. Louis?*

Yes

Are You Currently Homeless?*

Yes

Do You Currently…*

Own a Home?

Rent a Home?

Live with Family?

Live with Friends?

Do You Own a Car?*

Yes

Do You Have Any Pets? If YES, do not submit this form unless your pet is a service/assistance animal.*

Yes

Why Do You Want to Move?*

Household Member 2

Enter information about other members of your household here.

Name

First Last

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Relationship to You

PREFERENCES

Select Location Preference*

Rosie Shields

Vetter Place

No Preference

Unit Size Preference*

1 bedroom

2 bedroom

Preferred Move In Month*

Preferred Move In Year

HOUSEHOLD INCOME

You must have a minimum gross (before taxes) income (not including food stamps) of $1,250.00 per month for the entire household. If you have a Section 8 voucher, the minimum monthly income is $750.00. Please do not submit this form if you do not meet these conditions.

Employment Status*

Full Time

Part Time

Unemployed

Retired

Total Monthly Household Income (not including food stamps.)*

Sources of Income (Check all that apply)*

Employment

TANF

SSI

Alimony

Child Support

Food Stamps

Other

Do you have a housing subsidy?*

Yes

If you receive a housing subsidy, what type?*

Section 8

None

Other

RENTAL AND UTILITY PAYMENTS

Your eligibility will not be considered if you have an outstanding rental balance in excess of $1,000.00 or if you have any outstanding balance due to a utility service provider that prevents you from establishing new service in your name. Please do not submit this form if you do not meet this condition.

If you pay rent to a landlord, family member, or friend, what is your monthly rent rate?

If you are renting, are your rental payments up to date?*

Yes

If your rental payments are not up to date, what is the dollar amount past due for rent?

If you are renting, when is your lease due to expire?

Ameren UE*

Payments are up to date

Payments are past due

If past due, what is the amount owed to Ameren UE?

More About You

More information about you

Marital Status*

Never Married

Currently Married

Domestic Partner

Separated

Divorced

Widowed

Highest Level of Education*

Some High School

Still in High School or Working on GED

High School Graduate with Diploma

High School Graduate with GED

Some College

College Graduate

Advanced Degree

How Did You Hear About Beyond Housing?*

Beyond Housing Senior Living

Amenities include:

Senior Rental Housing Eligibility Form

Household Member 2

PREFERENCES

HOUSEHOLD INCOME

RENTAL AND UTILITY PAYMENTS

More About You

Reimagining Community