Interim Housing Request

"*" indicates required fields

Name
What are you applying for?*
Name Date of Birth (*Leave blank if unknown) Social Security Number (*Leave blank if unknown) Relationship to the Head of Household Gender Actions
         
What county are you currently residing?
Where did you sleep last night?*
Where are you sleeping tonight?*

Emergency Contact/Support Person
Emergency Contact/Support Person

I certify that all the information on this application is accurate and complete to the best of my knowledge.*Yes I authorize Have Mercy to complete a criminal background check for all adults in the household.*

Agency Agreement

I certify that all the information on this application is accurate and complete to the best of my knowledge. I authorized Have Mercy to complete a criminal background check for all adults in household.   I agree with the agency consent below:   CONSENT FOR AGENCY SHARING-HOUSING PROGRAMS: I understand that signing below is giving my consent allowing pertinent information listed to be shared among authorized personnel and partnering agencies to assist with provision of shelter and housing placement. All agencies, relevant to my shelter and housing needs, where I am receiving services may update information as I provide additional or new information. The purpose of sharing my information is to better coordinate shelter/housing needs for my household. This consent may be revoked at any time, through a written statement from me.*

FUNDED BY

United Way logo
Greenville Area Community Foundation
FEMA logo
MSHDA
mdhhs
salvation army

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