First Name

Last Name

Email

Phone Number

Date of Birth

Are You a Past MACV Client?

Current Housing Situation
–None–Emergency shelter, including hotel or motel paid for with emergency shelter voucherHospital or other residential non-psychiatric medical facilityJail, Prison or juvenile detention facilityLong-term care facility or nursing homePsychiatric hospital or other psychiatric facilitySubstance abuse treatment facility or detox centerHotel or Motel paid without emergency shelter voucherOwned by client, no ongoing housing subsidyOwned by client with ongoing housing subsidyPermanent housing for formerly homeless personsRental by client, no ongoing housing subsidyRental by client with VASH subsidyRental by client, with GPD TIP subsidyStreets/Place not meant for HabitationTransitional housing for homeless persons (including homeless youth)Staying or living in a family member’s room, apartment or housingResidential project or halfway house with with no homeless criteriaRental by client, with other ongoing housing subsidySafe HavenInterim HousingTransitional Housing

Household Composition
–None–Single AdultTwo Parent FamilySingle ParentFamily with Minor ChildrenOther

Total Gross Monthly Household Income Amount

County
–None–AitkinAnokaBeckerBeltramiBentonBig StoneBlue EarthBrownCarltonCarverCassChippewaChisagoClayClearwaterCookCottonwoodCrow WingDakotaDodgeDouglasFaribaultFillmoreFreebornGoodhueGrantHennepinHoustonHubbardIsantiItascaJacksonKanabecKandiyohiKittsonKoochichingLac qui ParleLake CountyLake of the WoodsLe SueurLincolnLyonMahnomenMarshallMartinMcLeodMeekerMille LacsMorrisonMowerMurrayNicolletNoblesNormanOlmstedOtter TailPenningtonPinePipestonePolkPopeRamseyRed LakeRedwoodRenvilleRiceRockRoseauScottSherburneSibleySaint LouisStearnsSteeleStevensSwiftToddTraverseWabashaWadenaWasecaWashingtonWatonwanWilkinWinonaWrightYellow MedicineOut of State

City

State

Branch of Service
ArmyNavyMarinesAir ForceCoast GuardNational Guard/ Reserves W/ Federal Active Duty TimeNational Guard/Reserves Without Active Duty Time

Discharge Type
–None–HonorableGeneral Under HonorableGeneral Other than HonorableBad Conduct (Special)Bad ConductDishonorableUncharacterizedUnknownStill Serving

Are You Service Connected?
–None–YesNo

Are You Connected to the CRRC or VAMC?
–None–YesNoDeclined to Answer

Please describe your situation and request.

Check if you need assistance related to Housing:

Check if you need assistance related to Employment:

Are Legal Issues Impacting Stability?
–None–YesNo

Check if You Are Impacted by the COVID-19 Pandemic?