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Independent Living Application
Marilyn's Independent Living Application
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*
" indicates required fields
Step
1
of
5
20%
Full Legal Name
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Date of Birth
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MM slash DD slash YYYY
Social Security Number (SSN)
*
Photo ID
*
Max. file size: 5 MB.
Current Location/Address
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Primary Phone Number
*
Emergency Contact
Target Population Verification (Check all that apply)
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Veteran
Currently Homeless
Recently Released from Incarceration
Date
*
MM slash DD slash YYYY
What is your current date of sobriety / clean time?
*
MM slash DD slash YYYY
Have you ever lived in a sober or transitional living facility before?
*
Yes
No
If yes, name of facility and reason for discharge
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Are you willing to submit to random drug and alcohol testing as a condition of residency?
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Yes
No
Do you have an external recovery support system (e.g., Sponsor, Therapist, Case Manager)?
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Yes
No
If yes, provide name and contact information
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Are you currently on parole or probation?
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Yes
No
PPO Name and Phone Number (Consent to contact is mandatory)
Have you been convicted of a sex offense or arson?
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Yes
No
Applicants with sex or arson offenses are automatically excluded due to safety and housing restrictions.
Do you have any pending warrants or court dates?
*
Yes
No
If yes, please describe
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What is your total verifiable monthly income?
*
Sources of Income (Check all that apply)
Employment (Full-Time / Part-Time)
VA Disability / Pension
SSI / SSDI
Other
Other (Please specify)
*
Are you currently employed?
Yes
No
If no, what is your plan for seeking employment/income?
Required to be enrolled in job search/vocational training.
Are you able manage your own medication?
*
Yes
No
Are you able prepare your own meals?
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Yes
No
Are you able to maintain personal hygiene and keep your living space clean?
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Yes
No
Do you understand that Marilyn's Independent Living does NOT provide medical, counseling, or therapeutic services?
*
Yes
No
Why do you believe Marilyn's Independent Living is the right environment for you at this time?
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Do you agree to abide by the House Rules, including the 11:00 PM curfew and mandatory weekly chore participation?
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Yes
No
INCOME VERIFICATION
Source of Income (check one or more):
Employment
Social Security (SSI / SSDI)
Unemployment
Pension / Retirement
Public Assistance (TANF, SNAP, etc.)
Other
Other (Please specify)
*
Employer or Agency Name
*
Contact Person (if applicable)
*
Phone / Email
*
Address
*
Monthly Income Amount
*
How often is this income received?
Weekly
Biweekly
Monthly
Other
Income Frequency is Other
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Length of time receiving this income
*
Example: 6 months, 1 year, 5 years
I, the undersigned applicant, hereby certify that the information provided in this application is true and complete. I understand that any false statement or omission may result in the immediate denial of my application or termination of residency. I authorize Marilyn's Independent Living to conduct background and reference checks, including contacting my parole/probation officer (if applicable), and I agree to abide by all facility policies and rules if accepted.
*
I undersigned
Date
MM slash DD slash YYYY
