[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-279473-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-279473-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","financial-assistance-assessment-application-form-housing-and-safety-needs","Financial Assistance Assessment - Application Form - Housing and Safety Needs","","Financial Assistance Assessment form collects household demographics, contact details, and eligibility information for housing-related support. It gathers background on safety concerns, including experiences of sexual violence or domestic violence, plus details about past abuse incidents and requested counseling support. The form also captures employment and income sources, monthly rent and lease information, prior evictions, utility arrears, ability to remain housed if paid, and referrals to Tri-Valley Haven. Applicants provide required documents such as ID, paystubs, lease or intent-to-rent letters, and financial statements, including a statement of need.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/financial-assistance-assessment-application-form-housing-and-safety-needs/279473/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/financial-assistance-assessment-application-form-housing-and-safety-needs/279473.png","ImageObject",442,249,{"name":42,"@type":43},"Caleb Sterling","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-04","2026-09-16",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information does the Financial Assistance Assessment form require from the household?","Question",{"text":63,"@type":64},"It requests household size, demographic details (including gender, race/ethnicity), contact information, date of birth, and marital status.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How does the form handle safety and violence-related questions?",{"text":68,"@type":64},"It asks whether the applicant is safe in their situation and whether they have experienced sexual violence or domestic violence, including timing of the last incident and whether counseling support is desired.",{"name":70,"@type":61,"acceptedAnswer":71},"What supporting documents must be submitted with the application?",{"text":72,"@type":64},"Applicants must include CA/State ID or passport, proof of income (last 3 months, or last year’s W2 if not working), and housing documentation such as a signed lease, intent to rent letter, rent ledger for back rent, and any past-due bills, plus bank statements for the last 3 months and a statement of need.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},279473,1790924836,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":121,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":26},962084925290,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Financial Assistance Assessment  \nDate of Assessment:  Household size:   \nFirst Name:  Last Name:   \nGender:  Female  Male  Transgender  Other   Date of Birth:  Age:  Marital Status:   \nPhone \\#:  Email:   \nCurrent Location:  City:  Permanent address:  City:   \nRace/Ethnicity:  \nAmerican Indian/Alaska Native:   American Indian or Alaska Native and Black/African American  \n______  \nAsian   American Indian or Alaska Native and White    \nAsian and White   Black or African American    \nWhite   Black or African American and White    \nOther Race Combinations   Native Hawaiian or Pacific Islander    \nDo you Identify as Hispanic and/or Latino   or Non-Hispanic or Latino    \nBackground:  \nAre you currently safe in your situation?  Yes  No  \nHave you experienced sexual violence?  Yes  No  \nHave you experienced domestic violence? (can be physical, verbal, emotional, financial) Yes  No  \nIf yes, what is your abuser’s name and you’re your relationship to the person   \n______________________________________________________________________________________  \nWhen was the last incident of abuse   Do you want to receive counseling support for your situation?  Yes  No  \nChildren:  \nFirst Name:   Last Name:  Age:   \nGender:  Race:  Date of Birth:   \n___  \nFirst Name:  Last Name:  Age:   \nGender:  Race:  Date of Birth    \nFirst Name:  Last Name:  Age:   \nGender:  Race:  Date of Birth    \nFirst Name:  Last Name:  Age:   \nGender:  Race:  Date of Birth    \nFirst Name:  Last Name:  Age:   \nGender:  Race:  Date of Birth  \n___________________  \nEmployment/Income:  \nAre you currently employed?  Yes No  \nName of employer:  Position:   \nPlease confirm your source(s) of income. Please check all that apply to you.  \n Employment  \n Child Support  \n SSI/SDI  \nWhat is your total monthly income from any source not including Food Stamps?    \nIf you are receiving Food Stamps or CalFresh, how much do you receive monthly    \nHousing:  \nWhat brought you into your housing crisis?  \n Have past due rent or are currently unable to pay rent  \n Unable to pay utility bills  \n Evicted or in the process of being evicted from your own housing  \n other:   \nHow much rent do you pay monthly? $  If you are on the lease, are you on the lease alone?  Yes  No If you answered No, please specify who else is on the lease.  \nFirst Name:  Last Name:   \nAge:  Date of Birth:  Relation to you:    \nDo you have a permanent mental/physical disability that has contributed to preventing you from  \nobtaining or maintaining housing?  Yes  No  \nHave you had any past evictions?  Yes  No  \nHave you recently been asked to leave your rental apartment or did the landlord use legal papers to ask  \nyou to leave?  Yes  No  \nIf you answered yes, when did this occur?  Do you currently have past due utility bills that may be at risk of service being shut off if no payment is  \nmade soon?  Yes  \n No  \nIf you have past due utility bills or rental payments, would you be able to stay in your current house if  \nthese were to be paid?  \nYes  \nNo  \nIf yes, please provide information regarding the type of bill and total amount due:  \nType of Bill:  \n   Amount due $   \n   Amount due $   \n   Amount due $    \n   Amount due: $    \nTotal $    \nRight now, are you receiving help related to your housing needs from any other agency, church or  \nperson?  Yes  No  \nIf yes, please describe who is helping you and what assistance you are receiving:  \nAre there currently any other challenges that are contributing as a financial hardship that may  \nprevent you from obtaining or sustaining your own housing?  Yes  No If yes, please explain:  \n___________________________________________________________________________________  \n___________________________________________________________________________________  \n___________________________________________________________________________________  \n___________________________________________________________________________________  \n________________________________________________________","cbCaieVtN7d5mXGN","https://ap.wps.com/l/cbCaieVtN7d5mXGN","pdf",305677,"English","# Financial Assistance Assessment\n## Household Information\n## Background and Safety\n## Children\n## Employment and Income\n## Housing\n## Supporting Documents and Referral","[{\"question\":\"What information does the Financial Assistance Assessment form require from the household?\",\"answer\":\"It requests household size, demographic details (including gender, race/ethnicity), contact information, date of birth, and marital status.\"},{\"question\":\"How does the form handle safety and violence-related questions?\",\"answer\":\"It asks whether the applicant is safe in their situation and whether they have experienced sexual violence or domestic violence, including timing of the last incident and whether counseling support is desired.\"},{\"question\":\"What supporting documents must be submitted with the application?\",\"answer\":\"Applicants must include CA/State ID or passport, proof of income (last 3 months, or last year’s W2 if not working), and housing documentation such as a signed lease, intent to rent letter, rent ledger for back rent, and any past-due bills, plus bank statements for the last 3 months and a statement of need.\"}]","Financial Assistance Assessment - Application Form - Housing and Safety Needs | PDF",1789521366]