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Homelessness Prevention Program
(HPRP)

Mississippi United To End Homelessness

Homeless Prevention and Rapid Re-Housing Program
Individual Request for Assistance

Please provide the following information in order for MUTEH to determine your eligiblity.

Name:
Address:
(continued)
City:
State:
MS
ZIP:
County:
Telephone Number:
Email (If Available):
Do you rent or own your home?
Current Household Income:
 
(Provide current income of all persons living in your household. This information will be verified by MUTEH staff at an initial interview.)
Are you currently homeless?
If yes, are you:
Are you currently at risk of homelessness?
If yes, are you:
I certify that the above information is true and correct, to the best of my knowledge. I understand that all information will be verified by MUTEH staff at an initial interview.
   
By checking "I Agree" you are consenting to this as your digital signature and verification of the above information.
I Agree
Date: 09-08-2010