Housing Services Intake Form – American Indian Family Center

Name*

First Last

Date of Birth

Residence*

Are you currently living in Ramsey County?

Yes
No

Tribal Affiliation*

Are you affiliated with any Tribe or First Nations?

Yes
No

Name of Tribe or First Nation

Which nation are you affiliated with?

If other, please identify which nation you are affiliated with?

Which nation are you affiliated with?

Employment*

Do you work or have an employer?

Yes
No

Unemployed?

If you are not employed, what are your current source(s) of income:

What is your households monthly income?*

Please provide your total monthly income for your household, do not include tribal payments.

Source of income*

Please list all of your primary source(s) of income:

Benefits*

Yes
No

Are you on any type of benefits including Childcare Assistance, MFIP, SNAP, MA or other government assistance programs?

Source of benefits

If yes, please identify which benefits are you currently receiving.

Household*

How many people are in your household?

Rent Amount*

This should be your standard rent charge each month. Please do not include past due balances.

Additional Agencies

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

Affiliation with AIFC*

Are you directly related to any AIFC staff members?

Yes
No

If yes, who?

Please identify which staff person(s) you are related to.

Request and Reason*

Briefly explain your current housing situation, including any eviction, utility shutoff, or homelessness you are facing, how if happened and why you need assistance.

Have you applied for Emergency Assistance?*

Yes
No

For the above request and reason, have you applied for emergency assistance?