Jump Start Interest Form

1. Do you currently reside in Hammond, Indiana?* YesNo 2. Which of the following best describes your current housing situation?*I am currently homeless (shelter, street, vehicle, or place not meant for habitation)I am fleeing or attempting to flee domestic violence, sexual assault, stalking, or traffickingI am at risk of becoming homeless soonI am currently housed but need rental assistance to maintain stabilityAre you experiencing domestic violence currentlyHave you experienced homelessness in the last two yearsNone of the above 3. Is your household income at or below 50% of the Area Median Income (AMI)? This would be for all adults (Example: For a household of 1, this may be around $28,000 annually—check with program staff for specific figures.) YesNoNot Sure 4. Are you or anyone in your household currently employed?YesNo If Yes, please be prepared to provide at least four (4) most recent paystubs for all employed household members. If paystubs are not available, acceptable alternatives include: - Employer verification letter - Bank statements showing direct deposits - Recent W-2 or tax return 5. How many people are in your household?*12345+ 6. Do you have any of the following household characteristics? (Check all that apply)*Senior (age 62+)Disabled individual(s)Child(ren) under 18 in the householdPregnant household memberNone of the above 7. What type(s) of support are you seeking? (Check all that apply)*Rental assistanceDisabled individual(s)Security deposit assistanceUtility assistanceCase management or supportive servicesHelp locating affordable housingOther If Other, Please specify 8. Are you currently receiving help from any other housing program?*YesNo If Yes, Please list

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