Homes for Hearts (HFH) Resident Agreement, Application & Intake Questionnaire  

Date:  ______________ 

Applicant Name: ___________________________________________________                                                 (Please Print clearly) 

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Below For Vetting Committee Use Only ========================================================================

                                                                                                             Date      

Application Received  By Vetting                                                ___________________   

Background Check Done                                              ___________________ 

Background Check Outcome                                                   ___________________   

Vetting Review Done                                                                    ___________________ 

Reviewers response          

Initial: _____         Candidate(Y/N): ___          

Initial: _____         Candidate(Y/N): ___          

Initial: _____         Candidate(Y/N): ___          

Initial: _____         Candidate(Y/N): ___          

Initial: _____         Candidate(Y/N): ___ 

1st Contact for Interview                               ________________________________ 

2nd Contact for Interview                             ________________________________ 

3rd Contact for Interview                              ________________________________ 

Interview Date                                                                            _________________   

Resolution and Date                 _________________                _________________ 

                                                                                              Homes for Hearts (HFH) Community Agreement

HFH is an affordable, permanent homestead that provides a safe and secure place to be for those currently without housing. It is a self-governing community that is based on five basic rules: 

1. No violence to yourselves or others 
2. No theft 
3. No alcohol, illegal drugs, or drug paraphernalia 
4. No persistent, disruptive behavior 
5. Everyone must contribute to the operation and maintenance of the Homestead. 

I will be a positive member of this community and contribute toward making it a safe, secure, clean and pleasant place to live. 

Therefore I agree to the following: 

• What I do will be based on love and respect for myself and others.  

• I will not disrespect others based on ethnicity, religion, gender, sexual orientation, handicap, lifestyle choices, or economic status.  We all have the right to expect dignity and opportunity. 

• I will help make HFH a place where everyone feels safe and respected.  For my own safety as well as the safety of others, I will not carry a weapon or act violently toward others or myself. 

• Since stealing is one of the most upsetting things that can happen in our community, I will not steal and will make the members of the Homestead Council aware of any stealing I see. I will respect other people’s property and community property and I expect other people to respect mine. 

• I know that illegal drugs and alcohol use can damage my community. I agree not to use illegal drugs or alcohol while at the Homestead.   

• I will honor quiet hours from 10PM to 7AM so that others and myself can stay healthy and rested. I understand that no personal guests will be allowed during that time. 

• I want to live in a clean, litter-free, comfortable space where I can bring friends, family and other guests.  Also, I know that many communities such as ours get closed down for “health and safety” reasons.  I will keep the area in and around where I live clean and orderly, and not store any personal items outside of my building footprint or allocated storage space. I will help keep the community areas clean and will pick up after myself and my pet, if I have one, and keep my pet leashed at all times. I understand that only a limited number of pets will be allowed in the Homestead in order to maintain an orderly environment.  

• I understand that in order to maintain a secure environment there will be a single point of entrance and exit that will be staffed 24/7, and that security shifts will be shared equally among Homestead residents. 
• I know that it can take a lot of work to keep the Homestead a safe, clean and pleasant place to live. I agree to work at least 10 hours a week on the operation and maintenance of the Homestead. This includes serving on security teams, helping with kitchen duties, construction projects, maintenance and clean-up crews, helping plan activities and other jobs that need to be shared by community members. 
• I also know that there are financial costs to keep the Homestead running.  I will support the goal of self-sufficiency by contributing each month either financially or through sweat equity by participating in micro-business opportunities or fundraising events. 

• I will attend the weekly Homestead meetings, unless I have an acceptable reason for absence, in which case I will find out what went on by reading the meeting notes.  I understand that decisions will be made through a majority vote, and that the Board of Directors of the non-profit reserves the right to override decisions made.  I agree to abide by all decisions made. 

• I affirm that I have completed the Background Check Form honestly along with all other application documents.  I understand that if the background check reveals otherwise, I could be asked to leave immediately.    

I promise to keep all of these agreements, as well as others that are approved at Homestead meetings.  If I violate any agreements, the members of the Homestead Council are authorized to ask me to leave temporarily, or, in serious or repeat cases, to leave permanently.  I will do so peacefully and not return unless I am authorized to do so. 

I know that HFH is a place where people value community and support each other.  I will try to think of ways to make our community a better place to be.  When I am concerned or upset with situations in the Homestead, I will bring these problems to the attention of the appropriate people so that we can work together to figure things out.  I willingly sign these agreements that are a contract between Homes for Hearts and me. 

Name (Signature): _____________________________________________________        

Date: __________________________

                                                                                           Homes for Hearts (HFH) Application & Intake Questionnaire 

Date: __________________   Legal/Given Name: __________________________________________________________________ 

Name Used: ________________________________________________________________________ 

Race/Ethnicity: ______________________       Gender: ___________________ 

Driver’s License/State ID number: ________________________  State issued: __________ 

How do we contact you?  

Location: ________________________________________________ 

Phone: __________________________________________________ 

Email: ___________________________________________________ 

Where did you sleep last night: ____________________________________________________________________________ 

Date of birth: _____________________                        Circle one:   Single / Married / Partnered

Is your spouse/partner applying to HFH?   Yes / No 

If so, spouse/partner’s name:_____________________________________________________ 

Do you have children with you?   Yes / No       If so, how old are they? ___________________ 

Do you have a car?   Yes / No                       Do you have an RV?   Yes / No 

How much stuff do you have?   Backpack / Car load / Truck load / Storage Unit 

Do you have a pet?   Yes/No  

If so, what kind? _____________ How many pounds? _____________ Spay/neuter?   Yes/No 

1. How did you become unhoused? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. How long have you been without stable housing? _________________________________________ 

3. Where was your most recent permanent address? _________________________________________ 

4. How long have you been in the Memphis/Tennessee Area? __________________________________ 

5. Is this your first experience being unhoused? ____________________________________________ 

6. Do you have a source of income?   Yes / No    If so, what source? ___________________________ 

7. Do you get food stamps?   Yes / No   If not, do you want help applying?   Yes / No 

8. Are you on OHP?   Yes / No   If not, do you want help applying?  Yes / No 

9. Do you receive SSI/SSDI?   Yes / No   If not, do you want help applying?   Yes / No 

10. Are you on any housing lists? Yes / No   If so, which? ______________________________ 

________________________________________   If not, do you want help applying?   Yes / No

11. Have you been active in houseless issues/activism?   Yes / No     If so, how? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. Have you ever lived in a rest stop, homeless village or other community environment?   Yes / No 

If so, which one and for how long? ________________________________________________

13. Are you a veteran?   Yes / No   Branch: _______________ Type of discharge: __________

14. Are you employed?   Yes / No   If so, where and how many hours/week? ________________________________________________________________________________________________________________________________________________________

15. Do you have a disability or special needs?   Yes / No     If so, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. Female head of household?   Yes/No  

17. Elderly head of household (over 65)?   Yes/ No 

18. What goals do you have for yourself? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

19. Is there anything you would like to tell us about yourself? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Skills Inventory

1. How far have you gone in school? _____________________________________________________ 

2. What did you study? _______________________________________________________________ 

3. Any plans to go back to school? Yes / No     To study what? ________________________________ 

4. Have you worked for pay?   Yes / No If so, what kinds of work have you done? 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. What is the best job you ever had? ____________________________________________________ 

Why? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. What are your hobbies? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________ 

7.What of the following do you have experience with? (Check all that apply) 

Rough Carpentry____  

Finish Carpentry ____ 

Plumbing ____

Electrical ____ 

Gardening ____ 

Farming ____ 

Security (Military/Law enforcement/Private) ____

Permaculture ____

HVAC ____  

Inventing ____

Masonry ____

Driver ____

Mechanic/small engine repair ____

Chimney Sweeping ____

Roofing ____ 

Cooking/Food Service ____ 

Computers, Web Development ____

Computers, Word ____ 

Processing/Spreadsheets ____ 

Computers, Data Entry ____ 

Computers, Desktop publishing ____ 

Writing ____ 

Business owner ____ 

Activism/Community Organizing ____ 

Management ____ 

Community/Political Leader ____ 

Masonry ____ 

Spiritual Leadership ____ 

Sales ____ 

First Aid ____ 

Bookkeeping/managing money ____ 

Computers, Programing ____ 

Office Manager ____ 

Other: ________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

8.Things you are interested in contribution to Homestead life:

Creative/Artistic ____

Communications/Outreach ____

Drawing, Illustration ____

Speaking/Presenting to groups ____

Writing – Promos, ads… ____

Filing ____

Stuffing Envelopes ____

Sewing/knitting ____

Coordination Volunteers ____

Bookkeeping/Accounting ____

Computer repair ____

Legal/Paralegal ____

Specific Software ____

Electrical ____

Medical/first aid (list certification) ____ / _________________________

Sign making/painting ____

Desktop publishing ____ 

Computer Graphics ____

Office and Administrative ____

Performance – acting, music, dance… ____

Cooking ____

Phone Calls ____

Computers ____

Networking ____

Note take, keeping minutes ____

Data Entry ____

Technical ____

Driving (list license type) ____ / ____________________

Carpentry ____

Plumbing ____

Roofing

Drafting/reading technical plans

Masonry

Leading work parties

Painting

Glazing

Landscaping

Gardening

Labor

Other: ________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

Please provide an Emergency Contact: 

____________________________________      _______________         _______________ Name                                                                      Phone                            Relationship

                                                                                              Homes for Hearts (HFH) Background Check Form 

Notice:  We will conduct a background check on all applicants. If that background check does not match your answers on this form, your application to live in Homes for Hearts will be denied. The only criminal offenses that automatically exclude are forcible/aggravated rape and sexual predation on children. PLEASE BE HONEST!

Last Name: ______________________  First Name: ______________________

Middle Name: ______________________ 

Date of Birth: ______________Last 4 digits of SSN:______________ 

Have you ever been convicted of a criminal offense? Yes / No 

If yes, please state the City/Town, County and State, the date of the conviction, and charges you were convicted of. (Please use the back of the sheet if you need more room). 

1. __________________________________    /   _______________

 City, State, County                                                 Date/Yr 

____________________________________________________________________________

Offense

2. __________________________________    /   _______________

 City, State, County                                                 Date/Yr 

____________________________________________________________________________

Offense

3. __________________________________    /   _______________

 City, State, County                                                 Date/Yr 

____________________________________________________________________________

Offense

The information on this form is true and accurate to the best of my knowledge. I give permission to verify all information provided. 

__________________________________________________  /  ________________________ Applicant Signature                                                                         Date 

__________________________________________________  /  ________________________ 

HFH Representative                                                                     Date