Housing Services Intake Form – American Indian Family Center

Name*

First Last

Phone*

Email

Residence*

Are you currently living in Ramsey County?

Tribal Affiliation*

Are you affiliated with any Tribe or First Nations?

Name of Tribe or First Nation

Which nation are you affiliated with?

Employment*

Do you work or have an employer?

Source of income

What is your primary source of income?

Benefits*

Are you on any type of benefits?

Source of benefits

Which benefits are you currently receiving?

Household*

How many people are in your household?

Rent Amount

If you have rent, what is the monthly amount?

Emergency Assistance*

Have you used emergency assistance?

Type of emergency assistance

What assistance did you receive and when was that assistance received?

Additional Agencies*

What other agencies have you worked with (if any)?

Affiliation with AIFC*

Do you have a family member or relative currently employed with AIFC?

AIFC Department

Which department at AIFC do they work with?

Request and Reason*

What is the reason for your request and what are your housing assistance needs?