LOW INCOME NON-MEDICAL HOUSING APPLICATION

For Indiana & Michigan Residents
(Non-medical | Utilities Included | No Care Services)

The SilverLining Foundation Inc.

Low-Income Non-Medical Housing Application

1. Applicant Information

Full Legal Name: __________________________
Date of Birth: __________________________
Phone: __________________________
Email (optional): __________________________
Current Address: __________________________

Emergency Contact (Name & Phone): __________________________

2. Income Verification

(Used solely to determine housing affordability eligibility)

☐ SSI
☐ SSDI
☐ Employment Income
☐ Pension / Retirement
☐ Other (specify): __________________

Monthly Gross Income: $____________

Do you have a representative payee? ☐ Yes ☐ No

Documentation Provided:
☐ Award Letter
☐ Pay Stubs
☐ Benefit Statement

3. Housing Eligibility (Non-Medical Scope)

This residence provides non-medical housing only. No medical, nursing, therapy, medication management, or personal care services are provided.

Please initial each:

___ I understand this is housing only.
___ I do not require on-site medical or nursing care.
___ I am able to arrange my own healthcare services if needed.
___ I am able to reside safely in a shared residential setting.
___ I can evacuate safely in case of emergency (with or without outside support).

4. Independent Living Confirmation

☐ I prepare my own meals.
☐ I manage my own medications.
☐ I manage personal hygiene independently or with outside assistance.
☐ I understand staff do not provide ADL assistance.

5. Rental Terms Acknowledgment

Utilities Included:
☐ Water
☐ Electricity
☐ Gas
☐ Trash
☐ Shared Common Areas

Food and personal items are the responsibility of the resident.

6. Fair Housing Statement

The SilverLining Foundation Inc. complies with the Fair Housing Act and does not discriminate based on race, color, religion, sex, national origin, disability, familial status, or lawful source of income.

Applicant Signature: __________________________
Date: __________________________