FLC Application

Application Section

Applicant Profile

Primary applicant identity, demographics, and background information.

First Name *

Last Name *

Today's Date *

Birth Date *

Age *

Social Security Number *

Gender *

Citizenship Status *

If Non-US Citizen COFA, select island

Primary Language *

Other Primary Language

Relationship to Head of Household *

Veteran Status *

YesNo

Race (select all that apply) *

Ethnicity *

Non-Hispanic or Non-Latin(a)(o)(x)Hispanic or Latin(a)(o)(x)

If Asian, select all that apply

If Native Hawaiian or Pacific Islander, select all that apply

Which race do you identify with most?

Application Section

Interpreter Services

Interpreter request and waiver information.

The Family Life Center (FLC) offers an interpreter at no cost when English is not the primary language. Use this section to indicate whether one is needed and whether FLC should provide it.

Application Section

Eligibility and Prior Support

Program acknowledgements, prior support, and housing urgency.

Applicant Name *

Email *

Phone Number *

Alternate Phone Number

Statement 1 Initials *

1. You will be asked to provide documentation proof of your current housing status, income, identity, birth record and social security number. You will be asked to provide other supportive documents necessary to assess your situation.

Statement 2 Initials *

2. You must show proof of any and all income sources. There must be an assurance that you will be able to continue paying for rent if you are to receive assistance.

Statement 3 Initials *

3. Assistance is limited to the availability of program funds.

Have you applied for or received financial support from other agencies within the last 12 months? *

YesNo

Agency Support History

Agency	Amount Received	Month(s) Given

Check only one housing status *

Application Section

Household Composition and Expenses

Household members, housing preference indicators, and expense screening.

Household Members

Member Full Name	Relationship	Birth Date	Age	Sex	Social Security No.

Are you currently homeless?

YesNo

If yes, please explain

Have you been (or are you about to be) displaced from your housing?

YesNo

If yes, please explain

Does your household have unreimbursed medical expenses in excess of 3 percent of annual income?

YesNo

Does your household pay childcare expenses for children under age 13 that enable a family member to work or go to school?

YesNo

Does your household pay care expenses for the care of a family member with disabilities that enable a family member to work?

YesNo

Application Section

Income, Assets, and Benefits

Income totals, detailed income rows, assets, and non-cash benefits.

Total annual income of all household members *

Average monthly income of all household members *

Income Details

Member Full Name	Income Source	Annual Amount	Payment Basis

Asset Information

Member Full Name	Type and Source of Asset	Cash Value of Asset	Annual Income from Asset

Non-Cash Benefits from Any Source

Other Benefit Source

Application Section

Health, Residency, and Landlord Information

Health coverage, disabling conditions, Hawaii residence details, and landlord contact information.

Application Section

Personal Information and Certification

Marital status, criminal justice status, and application certification.

I understand that the above information is being collected to determine if I/we are eligible to receive rental assistance. I/we authorize Family Life Center to verify all information provided on this application. I certify, on behalf of all household members, that the information given on this form is true and accurate to the best of my knowledge.

Marital Status

Other Marital Status

Current criminal justice status

Other Criminal Justice Status

I certify that the information provided is true and understand that fraudulent or willful omission may result in ineligibility to reapply for three years. * I certify that the information provided is true and understand that fraudulent or willful omission may result in ineligibility to reapply for three years.

Applicant Signature *

Choose Type or Draw in the signature modal. Your signature can be reused across this application.

Date *

Application Section

Consent to Release and Obtain Confidential Information

Consent for Family Life Center to release and obtain information needed to manage the case.

I authorize Family Life Center to release any information this agency has regarding my situation to agencies, organizations, or individuals that may need it in order to access services, obtain benefits, or advocate on my behalf. I also authorize Family Life Center to obtain information from agencies, organizations, or individuals as needed to manage my case. This agreement automatically expires twelve months after terminating my participation with Family Life Center programs. The participant completes the name, signature, and date below. Housing specialist lines remain internal staff documentation.

Participant Name (Print) *

Participant Signature *

Choose Type or Draw in the signature modal. Your signature can be reused across this application.

Date *

Application Section

State of Hawaii HMIS Release

HMIS informed consent for release of information for Bridging the Gap.

I understand that HMIS and CES are shared homeless and housing database systems used by homeless service providers throughout Hawaii. I give consent for my name and other relevant identifying information to be shared among Authorized Agencies to improve housing outcomes. This consent is valid for three years from the date of my signature unless I cancel it sooner in writing. The client and parent or legal guardian complete the fields below when applicable. Agency staff, program, and enrollment lines remain internal workflow items.

Print Name of Client *

Signature of Client *

Choose Type or Draw in the signature modal. Your signature can be reused across this application.

Date *

Print Name of Parent / Legal Guardian

Signature of Parent / Legal Guardian

Choose Type or Draw in the signature modal. Your signature can be reused across this application.

Guardian Signature Date

Application Section

Required Documents for Housing Assistance

Upload supporting documentation. The original packet notes that required documents should be submitted within 72 hours. Each document type accepts multiple files so applicants can attach the same grouped packet pages represented by repeated upload slots in Acrobat Sign.

Copy of photo ID

Copy of Social Security card for all family members

30 days of most recent pay stubs

Two months most recent bank statements (for all accounts)

Unemployment benefit statement

DHS benefit statement

SSI or disability benefit statement

Most recent tax return (1040 page)

Copy of rental lease, contract, or mortgage

W9 form from landlord

Eviction letter or Notice to Vacate

FLC Application for Assistance

Applicant Profile

Interpreter Services

Eligibility and Prior Support

Household Composition and Expenses

Income, Assets, and Benefits

Health, Residency, and Landlord Information

Personal Information and Certification

Consent to Release and Obtain Confidential Information

State of Hawaii HMIS Release

Required Documents for Housing Assistance

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