Homeless Prevention Program - Initial Assessment

Homeless Prevention Program - Initial Intake Assessment

(City of Plano HPP)
Date *

MonthDayYear
Client Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code*
Assess the Following

If any of the questions are falsified, your application will be DENIED and we will not be able to assist.
Have you been in your residence for 90 days?*

YesNo
Plano Resident*

YesNo
Notice to Vacate*

YesNo
Have you used this program in the last three years?*

YesNo
Do you receive Section 8?*

YesNo
Is the lease in your name?*

YesNo
Do you owe back rent?*
⚠️ Please Note If you owe back rent, you will not qualify for this program. We will provide a referral to another agency that may or may not be able to assist you with past-due rent.
How many are in your household?*
How many are children under 18 years old?
What is the amount of your rent?*
How many bedrooms?*
Are you currently employed?*

YesNo
What is your gross income (income before taxes)?*
Is that,*

WeeklyBi-WeeklyMonthlyN/A
What other Income Resources do you have?*

Child SupportSNAPSSI/Social SecurityRetirement/401 KOther
Result
If you qualify you will be able to submit, if there is no Submit button you did not qualify. Please wait for the case manager to call you and schedule an appointment. Make sure you are in the following zipcodes: 75074,75023,75024,75025,75075,75093,75094
Should be Empty: