Application for Eligibility

REMINDER: Please complete this form, sign the printed agreement and fax it, with documentation, to 'Social Services' at 1-866-941-7278.

Contact Information

Agency/Company
Apartment Complex Name:

Address:

DBA, if different:

Management Company,
if different:

City:

Main Contact:

State:

Title:

Zip:

Email:

Phone #:

ext

Fax #:

How did you hear about our Social Services Program?

	From an employer
	Through an Internet Search
	A Past-Employ.com representative called me and explained the service

	From an applicant
	I called the Client Service Center for assistance and the representative gave me this option.
Please enter the other way you heard about the program.
	Other:

Desired Start Date

Desired Start Date for Service:

Please note that it may take up to 3 business days to be
registered.

Tax Exemption Status

Is your agency tax exempt? Yes No

Agency Type

State or County Social Services/Human Services Agency

Social Security Administration

Work Program (WIA)

Housing Authority

If you are completing this agreement for a work program, you must provide the contract between your agency and the state or county.

Low-Income Housing (i.e. Sec. 8, Sec.42)

Child Support Enforcement

****Please provide proof of low-income status****

Third Party Vendor for Government Agency

Other

Specific Programs or Divisions that will use this Service

Food Stamps	TANF	General Cash Advance	Low-Income Energy Assistance
IEVS	Fraud Investigations	Quality Control	Housing Assistance
Title IV-D	Emergency Assistance	Title II	Title XVI
Collections	Pre-employment	Medicaid	Daycare Assistance
Work-related Assistance		Mortgage Loans	Apartment Complex
Other: In less than 75 words, please indicate other programs that will use this service:

Apartment/Property Management

	If you are an Apartment Complex or Property Management Company, please answer the following questions:
	How many units do you have?
		How many of those are subsidized units?
	Are you affiliated with City/State Housing Authority? Yes No
		If yes, please include the name:

In order to process your application, your agency/organization will need to provide proof of your need for employment and income verifications, as well as your agency/organization's program purpose.

Examples include:

Apartment Complex / Property Management	Other Agencies
HUD Rent Schedule Rural Development Rent Schedule Section 42 Certification L.U.R.A.: Land Use Restriction Agreement (it must specify the land will be used for low-income housing)	Copy of government contract Copy of grant letter Copy of annual report with funding detail Documentation indicating a relationship with a Government agency

Failure to provide supporting documentation may delay processing of your agreement or disqualify your application.

Signature

Print Name: _________________________________________________________

Signature: __________________________________________________________