Re-Apply for Housing Assistance

Please read each question carefully and provide all information requested.

Missing information may delay your application from being processed in a timely manner. Renewal applications are due July 11, 2025.

First Name

Last Name

Email Address

Date of Birth

YYYY

Current Address

Address where you currently reside

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County of Residence

Phone

(###)

###

####

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship to Contact

FINANCIAL INFORMATION

What is YOUR total annual gross income?

Please use the last 12 months.

What is your HOUSEHOLD’s current monthly gross income?

Include every earner in the household

What is your current monthly gross income?

SOURCES OF INCOME

Please put the amount AND if it is monthly/quarterly/yearly/etc. in each applicable box, and 0 if you do not have income in that category.

Live music (gig) shows

We realize that this can vary widely month to month so an average per month suffices here.

Recording or studio work

Royalties

Music lessons

Merchandise or Retail

Instrument repairs or manufacturing

Social Security (regular, disability, SSI)

Veterans benefits

Pensions

Unemployment

Annuities

Investments

Inheritance

Income from non-music related work (childcare, yoga, office work, etc)

Other income or financial assistance (please describe)

Number of your dependents if any (spouse, child, etc.)?

What was the last year you filed with the IRS?

LIVING SITUATION

Length of time at current residence

What is the current household size and make up of the home you live in? (This is the total number of people living in the household you reside in including yourself.)

What is the reason/s you have or would move?

(check all that apply)

Affordability

Rental property being sold

Roommate

Location

Poor Transportation Options

What is your current housing situation?

Own your home, rent month to month, share with others, etc.

What utilities are you responsible to pay monthly?

Include which utilities you pay and provide the average monthly amount for each.

If you rent or own, what is your current monthly mortgage or rent payment?

When does your current lease or living arrangement end?

Do you currently have any chronic illness or physical disability that make it hard for you to play/perform as a musician?

Please explain.

Do you have any special circumstances or special needs you can share that would tell us more about you and your situation?

Please explain.

GRANT INFORMATION

Requested Amount

What is the amount you are requesting, and how will you use it? Remember that HOME provides housing support and nothing else. This includes rent, deposits, and utilities mainly.

By submitting this form, I certify that all the information provided is true and correct to the best of my knowledge. I authorize HOME to verify independently any of the information provided in order to determine my eligibility. I further agree to allow HOME to make payments to any applicable housing vendors as needed to fulfill a grant award on my behalf and will cooperate fully by providing whatever is needed to accomplish this.

(Optional)

I further agree that should I be selected for a grant, that I will cooperate with any media related activity coordinated by HOME as a means to further raise public awareness of HOME and the needs of elder musicians and their housing needs. This may include but not be limited to: photos, interviews, statements requested or participation in HOME related events.

I give permission to use my name and likeness in promotional material

Date of Application Submission

YYYY