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Home Seeker Online Application
Thank you for your interest in HomeShare!
Please fill out all required information on this form and thoroughly read the
HomeShare Participation Agreement and Release
document and
Program Exit Guidelines
before electronically signing and submitting this online application. To participate in the HomeShare program, you must:
1)
Submit this online application after reading the Participation Agreement and Release document and the Program Exit Guidelines; and
2)
Email OR mail the signed
Applicant Background Check Form
and a copy of your Driver License or State I.D. to one of the following addresses:
EMAIL:
Home.Share@ventura.org
MAILING ADDRESS: HomeShare, 646 County Square Drive, Suite 100, Ventura, CA 93003
Personal Information
Name
*
First
Last
Date of Birth
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
SSN:
*
Phone #1
*
Phone #2
Select Phone #1 Designation:
*
Work
Home
Cell
Select Phone #2 Designation:
Work
Home
Cell
What was your sex at birth?
*
Female
Male
Decline to State
What is your Gender?
*
Female
Male
Transgender Female to Male
Transgender Male to Female
Genderqueer/Gender Non-binary
Decline to State
Not Listed
If not listed, please specify:
How do you describe your sexual orientation or sexual identity?
*
Straight/Heterosexual
Bisexual
Transgender Male to Female
Genderqueer/Gender Non-binary
Decline to State
Not Listed
If not listed, please specify:
Please indicate if you are a ...
*
Senior
Single Parent
Veteran
Student
Head of Household
Couple
Number in family:
1
2
3
4
5
6
7
8
9
Number of adults:
*
1
2
3
4
5
6
7
8
9
10
Number of children:
*
0
1
2
3
4
5
6
7
8
Preferred Language:
*
English
Spanish
Housing Needs
Dwelling Type(s) of Interest?
*
Townhouse
Condo
House
Apartment
Mobile Home
Granny Flat
All of the above
Able to Pay Monthly ($) (numbers only)
*
Current Monthly Rent ($)
Was Paying Monthly ($) *
Cities interested in:
*
Camarillo
Fillmore
Moorpark
Oak View
Ojai
Oxnard
Piru
Port Hueneme
Santa Paula
Simi Valley
Thousand Oaks
Ventura
All of the above
Minimum bedrooms needed:
*
1 Bedroom
2 Bedroom
3 Bedroom
Studio
Willing to share a bedroom?
*
Yes
No
Bathroom?
*
Private Only
Willing to Share
Need furnished room?
*
Yes
No
Have furniture?
*
Yes
No
Need storage?
*
Yes
No
Need parking?
*
Yes
No
Need public transportation access?
*
Yes
No
Need wheelchair access?
*
Yes
No
Need Internet access?
*
Yes
No
Do you have a car?
*
Yes
No
Driver License or I.D. #:
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Expiration Date
*
Service Exchange Desired?
*
Yes
No
If Yes - Check All Types of Exchange
*
Cooking
Childcare
Handyman/Garden
Light Chores
Heavy Chores
Transportation
In-Home Care
Companionship
Not Applicable
Comments About Service Exchange
Do you smoke?
*
Never
Regularly
Inside
Outside
Would you live with a smoker?
*
Yes
No
Outside Only
Do You Have Pets?
*
Yes
No
Comments
Would you live with pets?
*
Yes
No
Comments
Housing Situation
Housing Status
*
At-Risk
Homeless
Sharing
Have own place
Housing Assistance Currently Received:
*
Section 8
CalWORKS
HSA Rapid Rehousing
RAIN
Many Mansions
HA Waitlisted
Homeless/At-Risk Situation (check all that apply)
*
Eviction 30-day notice
Eviction 60-day notice
Accessibility issue due to disability
Living in car
Choose to stay in motel and can afford
Commute issues
Debt level too high
Domestic Violence
Drugs/alcohol in home
Emancipating from foster care
Fire
Foreclosure
Friend/family
Health care costs
Hospital
House being rehabbed
House was sold
Housemates stealing property
Income reduced and cannot afford rent
Landlord died
Lease expired
Lost job
Motel
No child support
Not getting along with family or housemate
Overcrowded
Owner/housemate giving up property
Provider needs the room
Rehab program
Relationship ending
Relocation to area
Dr./Family says needs assistance
Rent increase
Too expensive
Shelter
Transitional housing ended
None of the Above
Employment History
Employment Situation
*
Working Full-Time
Working Part-Time
Retired
Receiving SSI
Unemployed
Employer (if working) *
City
Job Title
Years at job
Employer (optional)
City
Job Title
Years at job
Annual Income ($) * (numbers only)
Income Source *
References
HomeShare asks for references in order for us to try to find the right person for you. Please provide 4 references, including 1 employment reference if applicable. Together the references should cover a span of at least 5 years to the present.
ACCEPTABLE
— Past or Present Roommates • Landlords • Employers • Co-workers • Friends • Neighbors
NOT ACCEPTABLE
— Family Members • Significant Others (e.g., boy/girl friends, spouses or life-partners)
Personal references known at least 5 years may be substituted for landlord or professional references at the discretion of HomeShare. Please notify your references that HomeShare will be calling them. Please understand that if you have trouble reaching them, we will have the same trouble, and your application may be delayed.
REFERENCE 1
*
First
Last
Phone
*
How long has this reference known you?
*
Less than 1 year
1-2 years
2-5 years
5+ years
Relationship
*
Roommate
Employer
Landlord
Colleague
Teacher
Advisor
Supervisor
Friend
Neighbor
REFERENCE 2
*
First
Last
Phone
*
How long has this reference known you?
*
Less than 1 year
1-2 years
2-5 years
5+ years
Relationship
*
Roommate
Employer
Landlord
Colleague
Teacher
Advisor
Supervisor
Friend
Neighbor
REFERENCE 3
*
First
Last
Phone
*
How long has this reference known you?
*
Less than 1 year
1-2 years
2-5 years
5+ years
Relationship
*
Roommate
Employer
Landlord
Colleague
Teacher
Advisor
Supervisor
Friend
Neighbor
REFERENCE 4 (optional)
First
Last
Phone
How long has this reference known you?
Less than 1 year
1-2 years
2-5 years
5+ years
Relationship
Roommate
Employer
Landlord
Colleague
Teacher
Advisor
Supervisor
Friend
Neighbor
Emergency Contact
Emergency Contact #1
*
First
Last
Phone
*
Relationship
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Emergency Contact #2
First
Last
Phone
Relationship
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Personal
Please provide the following personal details to help HomeShare find the right person for you.
Hobbies
*
Reason Seeking HomeShare Match
*
Ideal HomeShare
*
Special Qualities (optional)
Preferences
I would consider a housemate that is ...
*
Female
Male
Younger
Older
Different Race or Ethnicity
Different Religion
Identifies as LGBTQ
From Another Country
Non-native English Speaker
Family
Single Parent with Child
All of the Above
Race & Ethnicity
(Voluntary – for statistical purposes only)
Race – Please Choose One
*
American Indian or Alaska Native
Asian Indian
Black or African American
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Japanese
Korean
Laotian
Multiple Race
Other Asian
Other Pacific Islander
Other Race
Samoan
Vietnamese
White
Decline to State
Ethnicity
*
Not Hispanic/Latino
Hispanic/Latino
Decline to State
How did you hear of us?
Newspaper
HomeShare Client
Friend
Job
Brochure
Senior Center
Government Agency
Non-Profit
Internet
Presentation
Program Exit Guidelines & Participation Agreement
MUST READ before submitting application:
Program Exit Guidelines
HomeShare Participation Agreement and Release
Home Seeker Application Signature
I hereby acknowledge that all the information I have given in this application is true and complete to the best of my knowledge. I certify that I have read and agree to the 1) Program Exit Guidelines and 2) Participation Agreement and Release. I consent to having HomeShare check references and conduct a background check. Please fill out the
Applicant Background Check Form
to get started and email it to
Home.Share@ventura.org
or mail it to 646 County Square Drive, Suite 100, Ventura, CA 93003.
I understand that the information my references provide will not be disclosed to me as part of the screening process. I understand that false, misleading or incomplete information may make me ineligible to receive HomeShare services.
Signature
*
By typing your name and clicking the "submit" button below, you've electronically signed this application.
Date
*
Before You Submit!
Before submitting your application, please check below if you would like to have a VCAAA representative contact you with information about other Agency or Community services.
VCAAA services may be available if program eligibility requirements are met, and if funding for the services continues to be available.
VCAAA Services
Chore Services
Homemaker
Home Modifications
Personal Care
Respite
Counseling
Family Caregiver Assistance
Housing
Health Insurance Counseling and Advocacy Program (HICAP)
Information and Assistance
Long Term Care Services
MSSP – Case Management
Senior Support Line
Senior Nutrition
Transportation
Fall Prevention Classes
Matter of Balance
Stepping On Class
Tai Chi: Moving for Better Balance
Other Community Services
Adult Day Health Care
APS
Emergency Housing/Shelter Information
Grey Law
Gold Coast Veterans Foundation
HSA Homeless Services Resource List
Ombudsman
Support Groups
IHSS or other Caregiver
Other, Not Listed Above
A
A
A
© 2019 • Ventura County Area Agency on Aging
