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2. HOMELESSNESS PREVENTION REFERRAL TOOL
4. Eligibility Criteria:

   Families with children who are eligible for a prekindergarten through grade 12 academic program and are one of the following:

   • Living in overcrowded conditions in their current housing
   • Paying more than 50 percent of their income for rent
   • Lacking a fixed, regular, and adequate nighttime residence
6. Name of Adults in Home:
8. Date(s) of Birth:
10. Current Address/Living Situation:
12. Phone Number:
13. E-mail:
15. Preferred Method(s) of Contact

    1. Phone
    2. Email
    3. Text
17. Children Residing in the Home
19. Child 1 Name:
20. DOB:
22. School:
23. Grade:
25. Child 2 Name:
26. DOB:
28. School:
29. Grade:
31. Child 3 Name:
32. DOB:
34. School:
35. Grade:
37. Child 4 Name:
38. DOB:
40. School:
41. Grade:
43. Describe in detail your reason for seeking housing assistance:
45. If you are currently experiencing homelessness, please provide information on your housing plan. Include information on housing options/plans that have been explored, as well as rent and deposit needed:
47. Landlord Name:
49. Landlord Contact Information:
51. Permission to Contact

    1. Wadena County Human Services has permission to contact and share information with the landlord identified on this form
53. Current Monthly Rent / Mortgage Payment:
55. Monthly Family Income:
57. Income Type:

    Check all that apply

    1. Wages/Employment
    2. Social Security/SSI
    3. Veteran Benefits
    4. General Assistance
    5. Child Support/Spousal Maintenance
    6. Other
59. Other:
61. Which housing supports have you contacted?

    1. MAHUBE OTWA (218-632-3600)
    2. Wadena Housing and Redevelopment (218-631-7723)
    3. Rural Minnesota CEP (218-631-7660)
    4. Lutheran Social Services (218-824-1437)
    5. Wadena Ministerial Association
    6. County financial benefits (SNAP, emergency assistance) (218-631-7605)
    7. Other (list below):
63. Other:
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field