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Housing Interest Form
Please provide your details and preferences to express your housing interest.
Basic Information
First Name *
Last Name *
Phone Number *
Email Address *
Date of Birth *
Individual or family
Individual
Family
How many adults
How many children
Are you interested in a Traditional Rental or Affordable housing? *
Traditional Rental
Affordable Housing Options
Screening Questions
Are you comfortable living in a structured shared housing environment with house rules? *
Yes
No
Can you contribute toward monthly housing costs? *
Yes
No
Unsure
Are you willing to complete a full housing intake process if space becomes available? *
Yes
No
How did you hear about us? *
Please Select
Social Media
Oak City Cares
Wake County Reentry Council
Probation/Parole
Case Manager
Friend/Family
Other
Housing Needs
Lease Option: *
1-3 months
3-6 months
6-12
Monthly Housing Budget (include utilities) *
Program Information
Receiving SSI /Veteran Benefits *
Yes
No
Type of assistance: *
Medicaid
Food Stamps
Rental Assistance
Housing Voucher
Other
Current Employment Status *
Employed
Unemployed
Student
Retired
Unable to Work
Other
Employer Information
Employer Name
Position/Title
Supervisor Name
Employer Monthly Income
List all sources of income *
Caseworker Information
Are you currently working with a case manager, probation officer, parole officer, or housing navigator? *
Yes
No
Agency Name
Caseworker Name
Caseworker Email
Who is completing this form *
Agency
Applicant
Support Services Interest
Which support services are you interested in? *
Pantry
Rental assistance
Employment services
Transportation services
Peer support
Financial literacy
Background Information
Have you ever had an eviction? *
Yes
No
Have you ever been convicted of a felony? *
Yes
No
Nature of offense
Year convicted
Are you currently experiencing homelessness? *
Yes
No
Consent and Disclaimer
I understand this form places me on an interest list and does not guarantee housing. *
I agree to share my information with other housing agencies. *
Submit Interest Form
