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ADFA- HOME ARP Prescreen Questions
Please completely fill out the form below
* Indicates required question
Email
*
Record my email address with my response
Name
*
Your answer
DOB
*
Your answer
Contact Information
*
Your answer
What is your current situation?
*
Homeless ( living on the street, in a car or at a shelter)
Staying in the home of family or friend
I have a signed lease, I am behind on rent but not yet evicted
I have a signed lease with an eviction
Other
If you have a signed lease what is your current Address ( street, city, state, zip, county)
Your answer
How many bedrooms
1
2
3
4
N/A
Clear selection
What utilities are you responsible for?
Electric
Water
Gas
N/A
How much is your monthly rent?
Your answer
How much are you behind in rent?
Your answer
Who is your landlord?
Your answer
Do you have monthly income?
Yes
No
If you have monthly income, what is your gross monthly income? ( Social Security, disability, employment, child support, etc.)
Your answer
Are you receiving any other form of assistance?
Yes
No
Unsure
Clear selection
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