Housing Inquiry — Anchor Point Living Communities

Personal Information

Last Name *

First Name *

M.I.

Preferred Name

Pronouns

Date of Birth

Gender Identity

Age

Phone Number *

Email Address

Current or Last Known Address

City

Zip

Current Housing Status

Homeless / Unsheltered Emergency Shelter Transitional Housing Couch Surfing Incarcerated / Releasing Housed (seeking change)

Emergency Contact (Optional)

Contact Name

Relationship

Phone

Basic Housing Requirements

Source of Income (employment, SSI, etc.)

Monthly Income ($)

Employer / Income Source

Pay Frequency

Are you able to maintain monthly housing fees?

Yes No

How did you hear about us?

Word of Mouth Social Media Professional Referral (Optional) Search Engine Flier / Brochure Other

How were you referred? (Optional)

Contact Name

Phone

Shared Living Suitability

Are you able to live independently without help?

Yes No With Some Support

Have you lived in a shared/communal setting before?

Yes No

Do you smoke or use tobacco?

Yes No

Do you have a vehicle requiring parking?

Yes No

Move-In Timeline

Immediately Within 30 Days Within 60 Days Just Exploring

What are your housing goals? What does stability look like for you?

Is there anything else you'd like us to know?

Certifications, Agreements & Disclosures

Truthfulness: I certify all information is true and complete. False information may result in denial or termination of residency.

Non-Discrimination / Fair Housing: We comply with the Fair Housing Act, California FEHA (§12900), and Civil Code §51. We do not discriminate based on race, color, national origin, religion, sex, familial status, disability, sexual orientation, gender identity, source of income, age, or any other protected class.

Source of Income: Per California Gov. Code §12955, we accept all lawful sources of income including subsidies and vouchers.

Privacy / CCPA: Information is used solely for housing placement. You have the right to access, delete, or correct your data. We will not sell your data.

Consent to Contact: I authorize Anchor Point Living Communities to contact references, professional contacts (if provided), and prior housing providers as needed.

By submitting this form, I acknowledge that I have read and agree to the above statements. This inquiry does not constitute a lease or guarantee of housing.

Full Name (as signature) *

Date *

Personal Information

Last Name *

First Name *

M.I.

Preferred Name

Pronouns

Date of Birth

Gender Identity

Age

Phone Number *

Email Address

Current or Last Known Address

City

Zip

Current Housing Status

Homeless / Unsheltered Emergency Shelter Transitional Housing Couch Surfing Incarcerated / Releasing Housed (seeking change)

Emergency Contact (Optional)

Contact Name

Relationship

Phone

Basic Housing Requirements

Source of Income (employment, SSI, etc.)

Monthly Income ($)

Employer / Income Source

Pay Frequency

Are you able to maintain monthly housing fees?

Yes No

How did you hear about us?

Word of Mouth Social Media Professional Referral (Optional) Search Engine Flier / Brochure Other

How were you referred? (Optional)

Contact Name

Phone

Shared Living Suitability

Are you able to live independently without help?

Yes No With Some Support

Have you lived in a shared/communal setting before?

Yes No

Do you smoke or use tobacco?

Yes No

Do you have a vehicle requiring parking?

Yes No

Move-In Timeline

Immediately Within 30 Days Within 60 Days Just Exploring

What are your housing goals? What does stability look like for you?

Is there anything else you'd like us to know?

Certifications, Agreements & Disclosures

Truthfulness: I certify all information is true and complete. False information may result in denial or termination of residency.

Source of Income: Per California Gov. Code §12955, we accept all lawful sources of income including subsidies and vouchers.

Privacy / CCPA: Information is used solely for housing placement. You have the right to access, delete, or correct your data. We will not sell your data.

Consent to Contact: I authorize Anchor Point Living Communities to contact references, professional contacts (if provided), and prior housing providers as needed.

By submitting this form, I acknowledge that I have read and agree to the above statements. This inquiry does not constitute a lease or guarantee of housing.

Full Name (as signature) *

Date *

Personal Information

Last Name *

First Name *

M.I.

Preferred Name

Pronouns

Date of Birth

Gender Identity

Age

Phone Number *

Email Address

Current or Last Known Address

City

Zip

Current Housing Status

Homeless / Unsheltered Emergency Shelter Transitional Housing Couch Surfing Incarcerated / Releasing Housed (seeking change)

Emergency Contact (Optional)

Contact Name

Relationship

Phone

Basic Housing Requirements

Source of Income (employment, SSI, etc.)

Monthly Income ($)

Employer / Income Source

Pay Frequency

Are you able to maintain monthly housing fees?

Yes No

How did you hear about us?

Word of Mouth Social Media Professional Referral (Optional) Search Engine Flier / Brochure Other

How were you referred? (Optional)

Contact Name

Phone

Shared Living Suitability

Are you able to live independently without help?

Yes No With Some Support

Have you lived in a shared/communal setting before?

Yes No

Do you smoke or use tobacco?

Yes No

Do you have a vehicle requiring parking?

Yes No

Move-In Timeline

Immediately Within 30 Days Within 60 Days Just Exploring

What are your housing goals? What does stability look like for you?

Is there anything else you'd like us to know?

Certifications, Agreements & Disclosures

Truthfulness: I certify all information is true and complete. False information may result in denial or termination of residency.

Source of Income: Per California Gov. Code §12955, we accept all lawful sources of income including subsidies and vouchers.

Privacy / CCPA: Information is used solely for housing placement. You have the right to access, delete, or correct your data. We will not sell your data.

Consent to Contact: I authorize Anchor Point Living Communities to contact references, professional contacts (if provided), and prior housing providers as needed.

By submitting this form, I acknowledge that I have read and agree to the above statements. This inquiry does not constitute a lease or guarantee of housing.

Full Name (as signature) *

Date *

Personal Information

Last Name *

First Name *

M.I.

Preferred Name

Pronouns

Date of Birth

Gender Identity

Age

Phone Number *

Email Address

Current or Last Known Address

City

Zip

Current Housing Status

Homeless / Unsheltered Emergency Shelter Transitional Housing Couch Surfing Incarcerated / Releasing Housed (seeking change)

Emergency Contact (Optional)

Contact Name

Relationship

Phone

Basic Housing Requirements

Source of Income (employment, SSI, etc.)

Monthly Income ($)

Employer / Income Source

Pay Frequency

Are you able to maintain monthly housing fees?

Yes No

How did you hear about us?

Word of Mouth Social Media Professional Referral (Optional) Search Engine Flier / Brochure Other

How were you referred? (Optional)

Contact Name

Phone

Shared Living Suitability

Are you able to live independently without help?

Yes No With Some Support

Have you lived in a shared/communal setting before?

Yes No

Do you smoke or use tobacco?

Yes No

Do you have a vehicle requiring parking?

Yes No

Move-In Timeline

Immediately Within 30 Days Within 60 Days Just Exploring

What are your housing goals? What does stability look like for you?

Is there anything else you'd like us to know?

Certifications, Agreements & Disclosures

Truthfulness: I certify all information is true and complete. False information may result in denial or termination of residency.

Source of Income: Per California Gov. Code §12955, we accept all lawful sources of income including subsidies and vouchers.

Privacy / CCPA: Information is used solely for housing placement. You have the right to access, delete, or correct your data. We will not sell your data.

Consent to Contact: I authorize Anchor Point Living Communities to contact references, professional contacts (if provided), and prior housing providers as needed.

By submitting this form, I acknowledge that I have read and agree to the above statements. This inquiry does not constitute a lease or guarantee of housing.

Full Name (as signature) *

Date *

ANCHOR POINT LIVING COMMUNITIES

Housing Inquiry Form

Inquiry Received!

Personal Information

Emergency Contact (Optional)

Basic Housing Requirements

Shared Living Suitability

Certifications, Agreements & Disclosures

ANCHOR POINT LIVING COMMUNITIES

Housing Inquiry Form

Inquiry Received!

Personal Information

Emergency Contact (Optional)

Basic Housing Requirements

Shared Living Suitability

Certifications, Agreements & Disclosures

ANCHOR POINT LIVING COMMUNITIES

Housing Inquiry Form

Inquiry Received!

Personal Information

Emergency Contact (Optional)

Basic Housing Requirements

Shared Living Suitability

Certifications, Agreements & Disclosures

ANCHOR POINT LIVING COMMUNITIES

Housing Inquiry Form

Inquiry Received!

Personal Information

Emergency Contact (Optional)

Basic Housing Requirements

Shared Living Suitability

Certifications, Agreements & Disclosures