Are you the applicant or a nominator? *

Applicant

Nominator

APPLICANT INFORMATION

The following fields should be completed with the veteran's information.

What is the applicant's current residential status? *

Own/Mortage

Rent

Homeless

Number of children living with the applicant? *

Full Name *

Address

Street Address

City

State

Country

Enter your country

Postal Code

Phone *

Email *

Date of Birth *

Marital Status *

Single

Separated

Widowed

Married

Divorced

Has the applicant been convicted of a felony? *

Yes

Is the applicant able to help build their home? *

Yes

REFERENCES

Please list two professional references.

Reference 1

Reference 1: First Name *

Reference 1: Last Name *

Reference 1: Relationship *

Reference 1: Company *

Reference 1: Phone Number *

Reference 1: Street Address *

Reference 1: City *

Reference 1: State *

Reference 1: Zip Code *

Reference 2

Reference 2: First Name *

Reference 2: Last Name *

Reference 2: Relationship *

Reference 2: Company *

Reference 2: Phone Number *

Reference 2: Street Address *

Reference 2: City *

Reference 2: State *

Reference 2: Zip Code *

INCOME

Is the applicant currently employed? *

Yes

Does the applicant receive SNAP? *

Yes

Does the applicant receive Veterans Services? *

Yes

Does the applicant receive Medicaid? *

Yes

Does the applicant have Veterans Assistance (VA) health insurance? *

Yes

Does the applicant currently have a VA disability rating? *

Yes

Does the applicant receive Social Security? *

Yes

Does the applicant receive SSDI? *

Yes

Share any additional income for the applicant. Describe source and amount.

MOBILITY ISSUES/CONCERNS

If applicable, please tell us about any mobility issues the applicant may have (i.e. wheelchair bound, special equipment needed for bathing, etc.)

MILITARY SERVICE

Branch *

Choose one or more options

From *

To *

Discharge Type *

Choose one or more options

Can a copy of the applicant's DD214 be provided? *

Yes

Was the applicant ever deployed? *

Yes

DISCLAIMER & SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to housing, I understand that false or misleading information in my application or interview may result in my disqualification.

I understand that applying for a Tiny Home does not guarantee an interview.

Signature *

Clear

Today's Date *