The Center of Concern
Home Sharing
Inquiry Form

Mail to: The Center of Concern,      1530 N. Northwest Hwy., Suite 310,       Park Ridge, IL 60068


Date ___________________________


Name ____________________________________________________ Date of Birth ________________


Address ___________________________________City _________________ State ___ ZIP _________

Home Phone __________________ Work Phone ________________ Cell Phone _________________

Referred by ___________________________________   Limited English Proficiency ______________

Marital Status: Single ___ Married ___ Separated ___ Divorced ___ Widowed ___

Employment Status: Student ___ School ________________ Unemployed ___ Disabled ___ Retired ___

Employed   Part-time _____ Employer ____________________________________________

Full-time _____   Employer ________________________________________________________

Age preference ______________________   Gender preference ____________________________

Do you have any special needs? ________________________________________________________

Do you smoke? _____ Do you drink? ________


Home Provider:

Do you live alone? ______   If no, who else lives with you?   _________________________________

How much rent do you need? _______ What does rent include? ______________________________

Would renter have own room? ___ Is bathroom private?_____ shared?_____ Is room furnished?_____

Storage available? _____ Parking?______ How far to public transportation? ____________________


Home Seeker:

Affordable rent? ________________   When needed? ______

For you alone? _____ Children? _____ Ages ___________

Bringing furniture? ______ How much? _______________________________________________

Storage needed? ______________________________________________________________________

Need public transportation? _____  Current living situation _________________________________


We are obligated to collect the following information as part of a federal grant:

Annual income: Less than $9,000 ___ $9,000 to $16,000___ $16,000 to $26,400 ___

$26,400 to $38,000 ___ More than $38,000 ___

Ethnicity: Hispanic or Latino ___ Not Hispanic or Latino ___

Race: American Indian/Alaska Native ___ Black/African American ___

Asian ___ White ___ Native Hawaiian/Other Pacific Islander ___