HOPWA Application Name* First Last Social Security Number*Date of Birth* Phone*Email* Ethnicity*Ethnic data for statistical purposes only.HispanicNot HispanicRace*Racial data for statistical purposes only.WhiteBlack / African AmericanAmerican Indian / Alaska NativeAsianNative Hawaiian / Other Pacific IslanderDo you qualify for a reasonable accommodation due to a disability*YesNoIncome*Gross Income ($)How OftenIf Income is from Wages, List Name and Address of Employer Current Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How many household members?*In order to qualify for the HOPWA Program, you must meet all 3 of the following criteria. Documentation verifying these qualifications will be required at intake.Do you have proof of HIV seropsitivity for at least one household member?*YesNoIs your household gross income 80% of the area median income or below?*YesNoDo you currently live in Jefferson, Orange or Hardin county?*YesNoWhat is your current housing situation? Choose one of the following:*Homeless (living in emergency shelter, car, street, camping, etc.)Temporarily residing with family or friendsCurrently housed in rental housingCurrently housed in own home with a mortgageCurrently housed in transitional shelterCurrently incarceratedDo you have a pending eviction or foreclosure notice*YesNoWhat services do you currently need?*(Check all that apply) Short term assistance with rent (less than 6 months of assistance) Short term assistance with mortgage (less than 6 months of assistance) Short term assistance with utilities (less than 6 months of assistance) Long term assistance with rent (more than 6 months of assistance) Assistance with getting into a long term housing situation (assistance with security deposit, application fee, credit check, etc.) Access to Supportive Services (employment, education, life skills, health services, etc.) PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.