| | Foundation Dwellings | Information Sheet | | | | | |
| | Name: | Emergency Contact: | | | Current Source of Income: | | |
| | Social Security #: | Work #: | | | Job | | |
| | Date of birth: | Cell #: | c | | SSI/SSDI | | |
| | Health Program: | Relationship: | | | | W2 program/other | |
| | Medical conditions: | Alternate Contact: | | | Emergency contact’s name: | | |
| | Allergies: | Work #: | | | Home phone: | | |
| | Current medications: | Cell #: | | | Work phone: | | |
| | | Relationship: | | | | Cell phone: | |
| | | | | | | | |
| | | Applicants cell #: | | | | | |
| | Family doctor: | | | | Alternate contact’s name: | | |
| | Doctor’s phone: | Do you have a payee? | | | Home phone: | | |
| | Current Source of Income: | Do you have relatives residing in Wisconsin? | | | Work phone: | | |
| | SSI: | How long have you been a Milwaukee resident? | | | Cell phone: | | |
| | SSDI: | Would you like a case manager? | | | | | |
| | Job: | Do you use a cane, walker, or wheelchair? | | | | | |
| | W2 Program: | Do you own a car? | | | | | |
| | Other: | | | Terms of Housing Agreement | | | |
| | I ___am homeless, and am a guest (WI. Sa. 704.01) of Foundation Dwellings, which is located at 32 N. 8th Street Milwaukee, Wisconsin 53206. I understand that the room is at no cost to me for three days, which starts: ___and ends:_ I agree to peacefully leave the housing at that time. During the time of my stay I also agree to daily clean my room, clean up the bathroom after using it. And if I choose to cook my own meals, I agree to clean up after myself. Resident also agrees to not have overnight guests. | | I _ am homeless, and am a guest (WI. Sa. 704.01) of Foundation Dwellings, which is located at 3273 N. 8th Street, Milwaukee, Wisconsin 53206. I understand that the room is at no cost to me for three days, which starts:_and ends:__ I agree to peacefully leave the housing at that time. During the time of my stay I also agree to daily clean my room, clean up the bathroom after using it. And if I choose to cook my own meals, I agree to clean up after myself. | | | | |
| | Resident Signature and date:___ | | | | | | |
| | Owner Signature and date: | | | | | | |
| | ___ | Office notes | | | | | |
FOUNDATION DWELLINGS RENTAL APPLICATION
In regards to the property located at _, _, _ _
The Room and board has a monthly rent of $___ and a security deposit of $.__.
| 2. | The term of the tenancy shall be month to month starting __. A thirty day notice of vacating the premises is expected one month prior to leaving, and no later than the 5th of the month, or charges for the room will incur. |
| 3. | Tenant Information |
Full Name_
Phone ()_
Work Phone ()
Date of Birth: / _ /
Social Security Number __-_-___
Driver’s License #___
Full Name_
Phone ()_
Work Phone ()
Date of Birth: / _ /
Social Security Number __-_-___
Driver’s License #___
| 4. | Previous Residence Information |
| 1. | Previous Address ___ |
City : _ State : ___ Zip:
Length of occupancy: _
Phone: (__)_
Landlord’s Name:
Alternative Phone (__)___
Reason for leaving: _
Rent Payment $
| 5. | Vehicle Information |
| MAKE | MODEL | YEAR | COLOR | LICENSE PLATE# | STATE | PAYMENTS |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| 6. | Employment Information |
| Employer: | ___ |
| Dates Employed: | ___ |
| Position: | ___ |
| Supervisor: | ___ |
| Phone: | (__) _ |
| Salary: | $ _ per |
| 7. | |
| Employer: | ___ |
| Dates Employed: | ___ |
| Position: | ___ |
| Supervisor: | ___ |
| Phone: | (__) _ |
| Salary: | $ _ per |
| 8. | Banking Information |
| Name: | ___ |
| Account Type: | |
| ___ | |
| Account Number: | ___ |
| 9. | |
| Name: | ___ |
| Account Type: | ___ |
| Account Number: | ___ |
| 10. | |
| 11. | Credit Information |
Have you declared bankruptcy in the past seven (7) years? Yes [ ] No [ ].
If yes, please explain _
Have you ever been evicted from a rental residence? Yes [ ] No [ ].
If yes, please explain _
Have you had two or more late rental payments in the past year? Yes [ ] No [ ].
If yes, please explain _
Have you ever willfully or intentionally refused to pay rent when due? Yes [ ] No [ ].
If yes, please explain _
Have you ever been convicted of a crime, other than a traffic violation? Yes [ ] No [ ].
If yes, please explain _
We may run a credit check. Is there anything negative we will find that you want to comment on? Yes [ ] No [ ].
If yes, please explain _
If residing tenant is waiting for assistance from SSI, SSDI, or any other funding source to pay said property owner (Dawn Powell), the tenant will be responsible for all past due (accumulative) weekly/monthly rental and board charges; past due charges will be expected due when the tenant receives their awarded amount, or legal measures will be pursued for reimbursement.
A public records search will be conducted on each adult occupant. Any one or more of the following will result in automatic denial of the application:
| o | Felonies or misdemeanors involving sexual misconduct; |
| o | Felonies or misdemeanors involving the illegal possession, manufacture, sale, and/or distribution of a controlled substance; |
| o | Felonies involving a physical crime against a person or persons and/or another person’s property |
The parties hereby indicate by their signatures below that they have read and agree with the terms and conditions of this Agreement in its entirety.
| Landlord: Signature: ___ Date:___ Print: ___ Notary: | Tenant: Signature: ___ Print: ___ Date: Tenant: Signature: Print: Date:_ |
Foundation Dwellings
RELEASE OF MEDICAL AND PSYCHIATRIC RECORDS
Authorization For Release Of Medical Records
__ (name of hospital)
Patient’s Name and Address: _
Social Security Number: __
Birth Date: __
I authorize you to release to the persons listed below information concerning the medical and psychiatric evaluation and treatment received by the above named patient at (name of hospital) during the approximate period from (month & day), _ (year), to __ (month & day), __ (year). This information is to be used only for the purposes of ___
(assisting in the pursuit of a legal action and obtaining psychotherapeutic and medical care).
The authorized information is to be provided only to the following persons: _ _ _
(names and addresses of persons to receive information).
This authorization is valid for __ (number) days. I understand that I may revoke this consent at any time by sending a written notice to the _
__
(Director of Medical Records or the person authorized to release information or to supervise its release).
I understand that I may review the disclosed information by contacting the __ ___ (Director of Medical Records or the person authorized to release information or to supervise its release).
__
(Signature of Patient or Person Authorized to Consent For Patient)
___