Homeprovider Application

Name(Required)

Please include middle name, it is important for our records.

First Middle Last

Phone number(Required)

Email(Required)

Enter Email Confirm Email

Street Address(Required)

Please note: our program only serves home providers in Baltimore City and Baltimore County.

City(Required)

State(Required)

Zip Code(Required)

What county is your home located in?(Required)

Please note: Our program only serves Home Providers in Baltimore City and Baltimore County.

Baltimore City

Baltimore County

Gender(Required)

What best describes your household?

Female

Male

Nonbinary

Date of Birth(Required)

Contact person (if other than homeowner)

Contact Phone Number

How did you hear about St. Ambrose Homesharing?(Required)

Why do you want to share your home now?(Required)

Extra income

Companionship

To help others

All of the above

Other

Has your decision to look into home sharing been influenced by your mortgage payments, foreclosure, or risk of foreclosure?(Required)

Yes

How long have you lived in Baltimore?(Required)

How long have you lived in your current home?(Required)

Do you own your home?(Required)

If renting, please include a letter from your landlord indicating permission to sublet.

Yes

What is your marital status?(Required)

Who are the other occupants in your house and what are their ages?(Required)

Have you ever had a problem with alcohol or drugs?(Required)

Yes

If you answered yes, how long have you been clean and sober (minimum one year required)?

Have you ever been convicted of a crime?(Required)

Yes

If yes, please provide details as well as dates.

Please indicate your employment status:

Employed

Retired

Other

Employer Name

Employer Street Address

Employer City

Employer State

Employer Zip Code

Employer Phone Number

Your Position

Your household's yearly or monthly gross (pre-tax) income:(Required)

Source(s) of Income:(Required)

Examples: Employment, SSI, pensions, public assistance, etc. Please provide us with a copy of your documentation at the time of your interview.

Your highest level of education completed:(Required)

Do you have a health condition a homesharer should know about? If yes, please describe.

Your race (for grant reporting purposes only) – Please mark all that apply:(Required)

American Indian / Alaska Native

Asian

Black / African American

Hispanic

Native Hawaiian / Other Islander

White

Other Multi-Racial Category

Information for Homesharing

Describe the space available for a homesharer (1 room, 2 rooms, private bath, apartment, etc).(Required)

Is the space furnished (please describe)?(Required)

What is the desired rent you'd like to receive per month?(Required)

What is the minimum rent you'd accept per month?(Required)

Are utilities included?(Required)

Yes

Are you investigating other housing possibilities?

Selling

Moving

Other

BY COMPLETING AND SUBMITTING THIS FORM, I AGREE TO THE FOLLOWING:

All of the information above is correct to the best of my knowledge. I have read and understood that a $50 non-refundable application fee is due when I am interviewed after submitting this application (this is only paid one time). If a suitable match is found for me, I agree to pay St. Ambrose Homesharing the balance of 1/3 of one full month’s rent due at the time of the match meeting, usually 2 weeks after move-in. In the case of nonpayment of program fees, I understand that I will be billed for all Homesharing services rendered to me.

I agree to the above statement(Required)

Yes

CONSENT TO OBTAIN INFORMATION FORM

Please list the names of four people who have known you for AT LEAST FIVE YEARS that can serve as a personal reference for you. Include a former roommate or landlord and a combination of the following – one family member, professional person, associate, clergy, or friend.

Reference #1: Name(Required)

If applicable, choose the most recent person with whom you have lived.

Reference #1: Relationship(Required)

Reference #1: Phone Number(Required)

Reference #2: Name(Required)

Reference #2: Relationship(Required)

Reference #2: Phone Number(Required)

Reference #3: Name(Required)

Reference #3: Relationship(Required)

Reference #3: Phone Number(Required)

Reference #4: Name(Required)

Reference #4: Relationship(Required)

Reference #4: Phone Number(Required)

Comments

This field is for validation purposes and should be left unchanged.