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Housing Stability Utility Assistance Application

Household Overview

Today's Date *

Head of Household Name: First *

Last *

Date of Birth *

Address: Street Address *

Apartment / Unit

City *

State *

ZIP Code *

Phone Number *

Email Address *

How did you hear about us? *

What are your pronouns? *

What in your life currently brings you joy? *

If the applicant's primary language is not English and an interpreter is required, please list the primary language below:

Describe the expenses and the amounts that are you seeking assistance with:

What is the total amount requested? *

Briefly describe the circumstances that led to an inability to meet these expenses:

Briefly describe how you will be able to maintain your housing after receiving assistance from FDA:

List any other organizations that you have received financial assistance from in the past 12 months:

Household Members *Please list every person that lives in your household. You will be asked more information about each of these individuals on the next page of this application. Click "+" to add a new row.

Date of birth

Current Residence- where did you stay last night? *

If applicable, how long have you been without permanent housing?

Residence History (click "+" to add a new row for each previous address) *Provide your residence history, listing most recent first and including any amounts owed. Click "+" to add a new row.

Current Landlord Name *Write "N/A" if not applicable.

Current Landlord Phone Number

Current Landlord Email Address

For any previous evictions, provide dates and briefly describe grounds for eviction: Type N/A if not applicable *

If applicant receives a Section 8, other housing voucher or subsidized housing, please describe:

Have you have applied for Section 8 or other Subsidized Housing? *YesNo

If yes, state where and when.

Is anyone in your household a domestic violence survivor or currently fleeing? *YesNo

Has anyone in the household served in the US military? *YesNo

If yes, who?

Does anyone in the household have regular use of a vehicle? *YesNo

Has anyone in the household has been diagnosed with a physical or mental health concern? *YesNo

If yes, state who and the diagnosis.

Income and Assets

List ANY income from ALL household members received within the last 3 months as indicated.

Employment *Start with most recent. Click "+" to add a new row. If none, type "N/A."

Benefits *List ALL cash benefits and/or other income received by EACH household members in the past 30 days. Click "+" to add a new row. If none, type "N/A."

Non-Cash Benefits *List ANY other assistance received by EACH household member in the past 30 days (childcare, Food Stamps, Fuel Assistance etc). Click "+" to add a new row. If none, type "N/A."

Assets *List the value of any liquid assets for all household members as of date of application. Click "+" to add a new row. Type "N/A" if none.

Household Composition - PLEASE READ!

The next 5 pages of the application are for you to provide information about each member of your household. The first page is for the Head of Household, the next page is for Household Member 2, then Household Member 3, etc. If you do not have 5 people living in your household, please skip the pages you do not need. If you have more than 5 people living in your household, please email dhoward@frontdooragency.org.

Information for Head of Household

Name (Head of Household): First *

Last *

SSN: *

Date of Birth (Head of Household) *

Relationship to Head of Household *

Race (Head of Household) *American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

Ethnicity (Head of Household) *HispanicNon-Hispanic

Gender (Head of Household) *MaleFemaleTransgender female to maleTransgender male to femaleGender Non-conforming (not exclusively male or female)

Marital Status (Head of Household) *SingleMarriedDivorcedSeparatedWidowedLiving TogetherN/a

What type of health insurance does Head of Household have? *NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

What Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy Families

What is the highest level of education that Head of Household has earned? *

GED Earned?YesNoN/A

Is Head of Household currently enrolled in school? *YesNo

If yes, state the course and graduation date:

Is Head of Household now, or have they ever been, in a job-training program? *YesNo

If yes, where and what type of program?

Employment Status (Head of Household) *Full timePart timeUnemployed < 6 monthsUnemployed >6 monthsNot in work force

Does Head of Household require assistance with reading or writing? *YesNo

Please click "Save and Continue Later" often so you do not lose your progress.

Information for Household Member 2

If you do not have a 2nd member of your household, please skip this page.

Name (Household Member 2): First

Last

Date of Birth (Household Member 2)

Relationship to Head of Household

Race (Household Member 2)American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

Ethnicity (Household Member 2)HispanicNon-Hispanic

Gender (Household Member 2)MaleFemaleTransgender female to maleTransgender male to femaleGender Non-conforming (not exclusively male or female)

Marital Status (Household Member 2)SingleMarriedDivorcedSeparatedWidowedLiving TogetherN/a

What type of health insurance does Household Member 2 have?NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

What Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy Families

What is the highest level of education that Household Member 2 has earned?

Is Household Member 2 currently enrolled in school?YesNo

If yes, state course and graduation date:

Is Household Member 2 now, or have they ever been, in a job-training program?YesNo

If yes, where and what type of program?

Employment StatusFull timePart timeUnemployed < 6 monthsUnemployed >6 monthsNot in work force

Please click "Save and Continue Later" often so you do not lose your progress.

Information for Household Member 3

If you do not have a 3rd member of your household, please skip this page.

Name (Household Member 3): First

Last

Date of Birth (Household Member 3)

Relationship to Head of Household

Race (Household Member 3)American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

Ethnicity (Household Member 3)HispanicNon-Hispanic

Gender (Household Member 3)MaleFemaleTransgender female to maleTransgender male to femaleGender Non-conforming (not exclusively male or female)

Marital Status (Household Member 3)SingleMarriedDivorcedSeparatedWidowedLiving TogetherN/a

What type of health insurance does Household Member 3 have?NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

What Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy Families

What is the highest level of education that Household Member 3 has earned?

Is Household Member 3 currently enrolled in school?YesNo

If yes, state course and graduation date:

Is Household Member 3 now, or have they ever been, in a job-training program?YesNo

If yes, where and what type of program?

Employment StatusFull timePart timeUnemployed < 6 monthsUnemployed >6 monthsNot in work force

Please click "Save and Continue Later" often so you do not lose your progress.

Information for Household Member 4

If you do not have a 4th member of your household, please skip this page.

Name (Household Member 4): First

Last

Date of Birth (Household Member 4)

Relationship to Head of Household

Race (Household Member 4)American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

Ethnicity (Household Member 4)HispanicNon-Hispanic

Gender (Household Member 4)MaleFemaleTransgender female to maleTransgender male to femaleGender Non-conforming (not exclusively male or female)

Marital Status (Household Member 4)SingleMarriedDivorcedSeparatedWidowedLiving TogetherN/a

What type of health insurance does Household Member 4 have?NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

What Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy Families

What is the highest level of education that Household Member 4 has earned?

Is Household Member 4 currently enrolled in school?YesNo

If yes, state course and graduation date:

Is Household Member 4 now, or have they ever been, in a job-training program?YesNo

If yes, where and what type of program?

Employment StatusFull timePart timeUnemployed < 6 monthsUnemployed >6 monthsNot in work force

Please click "Save and Continue Later" often so you do not lose your progress.

Information for Household Member 5

If you do not have a 5th member of your household, please skip this page.

Name (Household Member 5): First

Last

Date of Birth (Household Member 5)

Relationship to Head of Household

Race (Household Member 5)American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

Ethnicity (Household Member 5)HispanicNon-Hispanic

Gender (Household Member 5)MaleFemaleTransgender female to maleTransgender male to femaleGender Non-conforming (not exclusively male or female)

Marital Status (Household Member 5)SingleMarriedDivorcedSeparatedWidowedLiving TogetherN/a

What type of health insurance does Household Member 5 have?NoneMedicaidMedicareState Children's Health Insurance ProgramVeteran's Administration (VA) ServicesEmployer Provided Health InsuranceHealth Insurance through COBRAPrivate Pay Health InsuranceState Health Insurance for AdultsIndian Health Services ProgramOtherChoose as many as apply. Hold down "Ctrl" and click to select more than one option.

What Managed Care Organization (MCO) do you work with?WellsenseAmerihealthNH Healthy Families

What is the highest level of education that Household Member 5 has earned?

Is Household Member 5 currently enrolled in school?YesNo

If yes, state course and graduation date:

Is Household Member 5 now, or have they ever been, in a job-training program?YesNo

If yes, where and what type of program?

Employment StatusFull timePart timeUnemployed < 6 monthsUnemployed >6 monthsNot in work force

Please click "Save and Continue Later" often so you do not lose your progress.

Monthly Household Income

Complete this page to the best of your ability, using MONTHLY amounts. False information will result in dismissal from this program.

Salary

SSDI

TANF

Social Security Income

Worker's Comp

Unemployment

Child Support

Alimony

Elderly Assistance

Pension

APTD

Food Stamps

Other Income Amount

TOTAL HOUSEHOLD MONTHLY INCOME

$

This field will auto-calculate based on your entries above. Food Stamps and Section 8/Rent Vouchers are not included in this total.

Please click "Save and Continue Later" often so you do not lose your progress.

Monthly Housing Expenses

Proof of all expenses must be provided at the time of appointment. Please include EVERYTHING you spend money on each month, including but not limited to; food, phone service, cable and internet, laundry, car payments, insurance, medications, loans, credit cards, recreation, etc. Use MONTHLY totals.

Rent/Mortgage Paid

Electricity

Gas

Phone Bill

Cable/Internet

Other

TOTAL MONTHLY HOUSING EXPENSES

$

This field will auto-calculate based on your entries above.

Household Expenses

Food

Toiletries

Diapers/Wipes

Laundry

Pet Food

Other Expense

TOTAL MONTHLY HOUSEHOLD EXPENSES

$

This field will auto-calculate based on your entries above.

Monthly Transportation Expenses

Car Payment

Gasoline

Car Insurance

Maintenance

Bus/Cab/Uber

Other Expense

TOTAL MONTHLY TRANSPORTATION EXPENSES

$

This field will auto-calculate based on your entries above.

Personal/Other Monthly Expenses

Credit Card Payments

Rent-to-Own

Loans

Child Support

Medications & Vitamins

Childcare

Hair & Nails

Donations

Cigarettes

School Lunches

Sports/Recreation

Other Expenses

TOTAL PERSONAL/OTHER MONTHLY EXPENSES

$

This field will auto-calculate based on your entries above.

Total Household Monthly Expenses

Total Household Monthly Expenses

$

This field will auto-calculate based on your entries above.

Total Monthly Disposable Income

Total Monthly Income - Total Monthly Expenses

Total Monthly Disposable Income

$

This field will auto-calculate based on your entries for total income and total expenses.

Please click "Save and Continue Later" often so you do not lose your progress.

Release of Information

By signing and dating below, I hereby authorize The Front Door Agency staff to contact past and present landlords and utility companies for the purpose of verifying information for my application for assistance, as well as any city, state or federal agencies that are providing me or anyone in my household with assistance.

Head of Houshold Signature: (type your full legal name) *

Date *

Co-Applicant Signature (type your full legal name)

Date *

Please click "Save and Continue Later" often so you do not lose your progress.

Save and continue later

Please do not fill in this field.

Contact Us

Main Office Address:
7 Concord Street
Nashua, NH 03064

Hours: Monday – Thursday
(8:30 a.m. – 4:30 p.m.)

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About Us
Programs
Events
- Gourmet Festival & Auction
- Open House
Give
Contact
DONATE
ADOPTER FORM