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CATHOLICOVA'! <br />CHARITIES <br />OF ORANGECCAIMY <br />Vx,hh NM4fry <br />Safely Home in Santa Ana <br />Eviction Prevention Program <br />Application (Page 1 of 2) <br />Name: Date: <br />Address: <br />City: Santa Ana <br />Phone: <br />State: CA Zip: <br />Email: <br />Total individuals in the household: Veterans in the household: <br />Adults: Seniors (62+): Children (over IS): Children (under 18): <br />How long have you been at this address?: years months <br />Have you received rental assistance through the Safely Home in Santa Ana program before <br />through Catholic Charities or The Salvation Army? ❑ Yes ❑ No <br />(I£ yes, referrals will be provided If no, continue completing application) <br />Have you been helped by other agencies/organizations? ❑ Yes ❑ No <br />If yes, which ones? <br />How long ago? What type of assistance? <br />Who referred you to CCOC or TSA? <br />Have you ever been homeless? ❑ Yes ❑ No <br />If yes, when? <br />For how long? <br />Employment/Income: <br />Employment Status: ❑ Employed FT ❑ Employed PT ❑ Unemployed <br />Monthly Household Income: <br />❑ Wages/Salaries ❑ Gen. Relief <br />❑ Unemployment ❑ Calworks <br />❑ Other Income: <br />(including benefits/aid) <br />❑ SSI/SSDI ❑ Child Support ❑ V.A./Retirement <br />❑ IHSS ❑ CalFresh/Food Stamps <br />Monthly Rent: ❑ Section 8 <br />