Step 1 of 19

Complete Legal Name*

First Middle Last

Nickname (or other names used)

Date of Birth*

Month

Day

Year

Place of Birth*

Social Security #*

Driver's License/State ID #

State of Issuance

Cell Phone

Work Phone

Do you currently have a case manager?*

Yes

Case Manager Name*

Agency*

Case Manager Phone*

Income

List all sources of income and expenses. Sources of income must be verifiable. Please attach copies of documentation (i.e. pay stubs) that will assist us in verifying a stable source of income.

Earned Income (Job)

Unemployment Insurance

Supplemental Security Insurance (551)

Social Security Disability Insurance (5501)

VA (Service Connected Disability)

VA (Non-service Connected Disability)

Private Disability Insurance

Worker's Compensation

General Assistance

Social Security Retirement

Pension/Retirement from Job

Child Support

Alimony/Spousal Support

SNAP (Food Stamps)

WIC

Section 8/Public Housing/Rental Assistance

Temporary Assistance

Other

Total Income

Expenses

Phone

Car Payment/Insurance/Maintenance

Food

Transportation/Gasoline

Medical (Dr, prescriptions, etc.)

Other

Total Expenses

Employment

Are you currently employed?*

Yes

Employer*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Employment Status*

Full Time

Part Time

Temporary

When Did You Start This Job?*

Month

Day

Year

Medical

Are you currently covered by health insurance?*

Yes

Program*

You are required to attach a copy of your health insurance card. This application is not complete without proper documentation of health insurance.

Do you have a primary care provider?*

Yes

Provider Name and Location*

Do you have a mental healthcare provider?*

Yes

Provider Name and Location*

Are you a victim or survivor of domestic violence?*

Yes

When did this occur and by whom?*

Do you have a medical marijuana license or do you take any controlled substances that are prescribed to you?*

Yes

Do you currently have any drug or alcohol addiction issues?*

Yes

Have you had drug or alcohol issues in the past?*

Yes

Are you willing to submit to a drug test?*

Yes

Do you smoke?*

Yes

Have you had an incident of bed bugs in the last 12 months?*

Yes

Are you currently receiving community services?*

Yes

Are you willing to receive services while living at Eden Village?*

Yes

What community services are you receiving?*

Do you have any of the following End of Life Documents? Check all that apply.

Declaration of Guardian

Directive to Physicians

Durable Power of Attorney

HIPAA Release

Death Certificate Information Sheet

Criminal History

Have you ever been arrested?*

Yes

If yes, what were you charged with?*

Have you ever been convicted of a felony?*

Yes

Please explain about your felony conviction*

Do you have any open legal cases filed against you?*

Yes

Do you have any pending charges against you?*

Yes

Are you currently on probation?*

Yes

When does your probation end?*

Explain the details of your probation*

Are you a registered sex offender?*

Yes

Explain your registration status and requirements*

Do you currently have any outstanding warrants for your arrest?*

Yes

Please explain about the warrants*

Have you ever been arrested and/or convicted of domestic violence?*

Yes

Please explain about your arrest or conviction*

Educational Background

Highest Level of Education Completed*

Do you have difficulty with reading or writing?*

Yes

Please explain your difficulty*

Have you ever served in the military?*

Yes

Branch*

Veteran Status*

Do you have a copy of your DD-214?*

Yes

Additional Information

Do you have children that are minors?*

Yes

Do you own any animals?*

Yes

Type of Animal*

Breed*

Approximate Weight*

Do you own a car that will be parked on the property?*

Yes

Make & Model*

You are required to show proof that your car’s registration is up-to date. Please note that vehicles are prohibited from parking on the premises if they are inoperable, have no license plate, no current registration, or no current registration sticker. This application is not complete without attached proper documentation for any cars you own.

Have you ever been evicted from housing in the past?*

Yes

Please explain more about your eviction*

Personal References

List 3 people who are NOT family members and can serve as a personal reference.

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Reference 2

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Reference 3

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Professional/Agency References

List 3 people who are NOT family members and can serve as a personal reference.

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Reference 2

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Reference 3

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contacts

List 3 people to contact in case of an emergency.

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Contact #2

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Contact #3

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Qualifying Disability and Homelessness Verification

Eden Village defines a chronically homeless person as – an unaccompanied homeless person (a single homeless person who is alone and is no part of a homeless family and not accompanied by children) that meets 3 specific criteria. The following questions will determine your eligibility for Eden Village.

Part 1: A Disabling Condition

Do you have any disabilities?*

Yes

What are your disabilities? Check all that apply.*

Alcohol Abuse

Alzheimer’s/Dementia

Cognitive

Developmental

Drug Abuse

Hearing

HIV/AIDS

Learning

Mental Handicap/Injury

Mental Illness

Physical/Medical

Physical/Mobility

Speech

Visual

Other

Other Disabilities*

What medical or mental diagnosis do you have?*

Are each of the disabilities listed above expected to be of a long, continued and indefinite duration and substantially impair your daily life?*

Yes

Which disabilities do not?*

Which of the above disabilities are you currently in treatment for?*

Part II: Duration in Kansas City Metropolitan Area

How long have you lived in the Kansas City Metropolitan Area?*

Part III: Chronically Homeless Status

Knowing that…

Episodes (“occasions”) of homelessness are broken up by and period of time where the client was housed for 7 days or more
Transitional housing and hotels or motels paid for by the client are classified as housing for those eligibility purposes
The following are classified as emergency shelters: HCHV contract beds and hotels or motel is paid for by charitable organizations or by federal, state and local government programs (TDCJ, HOPWA, etc.)
Institution stays of less than 90 days are considered a continuation of homelessness, if the client entered from a place not meant for human habitation, emergency shelter or save haven; if the institution stay is greater than 90 days, this constitutes a break in homelessness.

Have you been continuously homeless for a year or more?*

Yes

HUD defines “homeless” as “a person sleeping in a place not meant for human habitation” e.g. living on the streets OR living in a homeless emergency shelter.

Describe homelessness over the past 12 months. Include all dates and locations (i.e. [month/year] to [month/year] at [location]):*

In the last three (3) years, have you been literally homeless on four (4) or more separate occasions, which total at least 12 months?**

Yes

HUD defines “homelessness” as “sleeping in a place not meant for human habitation” e.g. living on the streets OR living in a homeless emergency shelter.

Document all episodes of homelessness in the last three (3) years. Add one episode per line.*

Sum of Homeless Occassions (in months)*

Verification Documents

Part III is supported by Third Party Certification, which includes dates and locations of homelessness, from one or more of the following documents. Upload all that apply.

Certification letter(s) from an emergency shelter for the homeless.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 250 MB.

Certification letter(s) from any other health or human service provider.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 250 MB.

Certification letter(s) from a homeless service provider or outreach worker.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 250 MB.

Favorites

As a neighbor of Eden Village we want to get to know you better! Please let us know some fun facts about yourself.

What are your favorite sports teams?

What is your favorite hobbies or skills?

What are your favorite foods?

What type of music do you like?

Like to read? What books?

What is your favorite holiday?

What do you dream of being able to do?

Where do you see yourself in 5 years?

Required Documents Upload

Photo ID*

Accepted file types: jpg, png, gif, heif, pdf, Max. file size: 64 MB.

Drivers License or State ID.

Income Verification Documents*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Upload a copy of any proof of income that you receive. This can be a pay stub or monthly statement.

Proof of Insurance*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Upload a copy of your insurance card or other documentation.

Vehicle Documentation*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Upload a copy of your vehicle registration for each vehicle you own.

Pet Documentation

Drop files here or

Accepted file types: job, gif, png, pdf, Max. file size: 64 MB.

You stated that you have a pet. If you have any documentation such as shot records or license please upload it here.

Statement of Independence

Eden Village of Kansas City is an innovative program of Three Dog Night Charities and is designed to provide independent, affordable, sustainable housing with dignity to those who are experiencing chronic homelessness. Chronic homelessness is defined as being continuously homeless for one year or more or being homeless at least four times for long durations over the past three years or living in a place not meant for human habitation. It is the expectation that all applicants will be able to live independently as single occupants in a home in a community environment. The occupant(s) will be expected to maintain a clean and orderly home. Eden Village of Kansas City staff will make random and periodic inspections to ensure the home is kept in an orderly fashion. Eden Village does not provide case management services or counseling. (Medical or psychiatric care, house cleaning, transportation, etc.) Most of the services that an applicant may need will be obtained from outside sources and made available in the Eden Village of Kansas City’s Resource Center. Eden Village of Kansas City and applicant(s) acknowledge that it is very difficult to live on a limited income. It will be important for the applicant(s) to understand what other services are available in the city that would help offset the cost of everyday living.

Certification*

I agree

By signing this document with my digital signature, I attest that I am financially, physically and emotionally fit to live independently as set out above. All information provided is true and accurate. I understand that any inaccuracy or incomplete information provided could cause my application to be rejected.

Certification*

I agree

By signing this application, I guarantee the accuracy and completeness of the information provided. I also give Three Dog Night Charities permission to have a Public Data Search and a criminal background check conducted on me.

Digital Signature*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Resident Application

Income

Expenses

Employment

Medical

Criminal History

Educational Background

Additional Information

Personal References

Professional/Agency References

Emergency Contacts

Qualifying Disability and Homelessness Verification

Part 1: A Disabling Condition

Part II: Duration in Kansas City Metropolitan Area

Part III: Chronically Homeless Status

Verification Documents

Favorites

Required Documents Upload

Statement of Independence