Bridges Application	

Please contact a Bridges provider to determine if you meet the priority population requirement and eligibility criteria. This application is for provider distribution use only.

	Bridges Application	

This application is for the Bridges Program only. Read the instructions for each section and answer all required questions. Incomplete applications will slow processing and may be returned. Once completed, please give this form to your local Housing Agency. Do not send it to Minnesota Housing.

Housing Choice Voucher Requirement
To receive Bridges rental assistance, you must also apply for a Section 8 Housing Choice Voucher. If the waiting list is currently closed, you must apply as soon as the waiting list opens and provide evidence of your application. Failure to do so will result in termination from the Bridges program, and you will no longer receive a rent subsidy.

Have you applied for a Section 8 Housing Choice Voucher?	      
 YES – Complete the application information below.    

Housing Authority Name	Date of Application	
     	     	
     	     	
     	     	
  
 NO – The waiting list is closed. The anticipated date the waiting list will open is       . Do you understand that you must apply as soon as the waiting list opens, even if you have a Bridges voucher?   YES   NO

Personal Information
Name:      	
Address (if applicable):      	
City:      	                                      	State:      	Zip:         	County:      	
Home Phone:      	Work Phone:      	
Email (optional):      	

Extent of homelessness prior to program intake:  
  Not homeless		                1st time homeless                                    2nd or 3rd time homeless
  Long-term homeless (homeless for 12 or more consecutive months or four times in the last three years)

Living situation prior to program intake:
  Emergency shelter	  Jail, prison, other correctional facility	  Nursing home	
  Transitional housing	  Board and Lodge	  Group home or foster care	
  Permanent supportive housing	  Hotel/motel without voucher	  Place not meant for habitation	
  Psychiatric facility or hospital	  Living with family  	  Don’t know	
  Hospital (non-psychiatric)  	  Living with friends   	  Refused		
  Substance abuse treatment or detox

	  Rental house/apartment     	  Other:      	

Emergency Contact 	
Name:      	
Address:      	
Phone:      	Relationship:      	
Case Manager (if applicable)	
Agency:      	
Name:      	Phone:      	
Address:      	
Crisis Assistance Organization	
Agency:      	Phone:      	

Household Information
Family Status (check all that apply):   

Head of household or spouse is 62 or older            		 Another family member is handicapped or disabled
Head of household or spouse is handicapped or disabled          None of the above

Marital Status:	

Married	Unmarried 	Separated	Divorced

List the head of household and all other individual(s) who will be residing in the unit. Include the relationship of each family member to the head of household. 

Full Name	Relationship	Birth Date	Age	Sex 	Social Security Number	
     	HEAD	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	

You are not required to provide race and ethnicity information, but supplying it will help with monitoring and determining compliance with civil rights laws.

Race of Head of Household	Ethnicity of Head of Household	
Asian 	Hispanic	
Black/African American	Non-Hispanic	
Native American/Alaskan Native		
Native Hawaiian/Pacific Islander		
White		

Income Information
Include income for all household members age 18 and over. Income eligibility will be recertified annually. You are responsible for immediately notifying your local Housing Agency, in writing, if your income changes at any time while receiving assistance.  

YES	NO
		1.  Do you work full-time, part-time or seasonally?
		2.  Do you expect to work for any period during the next year?
		3.  Do you work for cash?
		4.  Do you expect a leave of absence from work due to lay-off, medical, maternity or military leave?
		5.  Do you receive or expect to receive unemployment benefits?
		6.  Do you receive or expect to receive child support?
		7.  Are you entitled to child support that you are not receiving?
		8.  Do you receive or expect to receive alimony?
		9.  Are you entitled to alimony that you are not receiving?
		10. Do you receive or expect to receive public assistance (TANF, MFIP, GA, FGA)?
		11. Do you receive or expect to receive Social Security benefits (SSI, MSA, SSDI, RSDI)?
		12. Do you receive or expect to receive income from a pension or annuity?
		13. Do you receive or expect to receive regular contributions from organizations or from individuals not 
 living with you?
		14. Do you receive income from assets, including interest on checking or savings accounts, interest and 
 dividends from certificates of deposit, income or interest from stocks or bonds, or income from rental property?
		15. Do you own real estate or any asset for which you receive no income (checking account, cash)?
		16. Have you sold or given away real property or other assets (including cash) for less than their fair 			       market value during the past two years?  If yes, when       Amount      	
Type of Asset      

For each YES above, provide income details below. Add additional pages, if necessary, as well as the name and address of employers. Be sure to list gross income (pre-tax income) for wages, Social Security and Medicare. 

# (1-16 above)	Explanation of Income	Monthly Income Amount	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
				Total 	     	

Employment	
Name and address of current employer, if applicable:
     	Length of employment:
     	
Supervisor’s name:
     	Supervisor’s phone number:
     	
Name and address of current employer, if applicable:
     	Length of employment:
     	
Supervisor’s name:
     	Supervisor’s phone number:
     	

Assets
All household members’ assets must be included below. 
Bank or Agency Name	Type of Account	Account Number	Balance	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	

You may be required to provide evidence of income and assets including:
•	Benefit award letters from Social Security, MSA, GA, etc. 
•	Payroll check stubs showing hours worked and rate of pay (provide, at a minimum, one month)
•	Copy of a recent bank statement showing the account balance and interest rate 
•	Any other documentation of income and assets that may be available 

Applicant Certification 
The application must be filled out completely and signed by the applicant and all other adults 18 or older living in the household.

With my signature below, I verify that:
•	I have provided true and correct information on this application, to the best of my knowledge and belief.
•	I have read and understand the information contained on the Government Data Practices Act Statement and Authorization to Obtain Information, and acknowledge so by signing said form (attached).
•	Assistance through the Bridges Program is temporary and will continue only until Section 8 assistance or another permanent subsidy is obtained.

	       	
Head of Household’s Signature                                                                       	Date	

	       	
18+ Household Member’s Signature                                                                    Date	

	       	
18+ Household Member’s Signature                                                                    Date	

	       	
18+ Household Member’s Signature                                                                    Date	

	       	
18+ Household Member’s Signature                                                                    Date