Please contact a Bridges provider to determine if the applicant meets the priority population requirement and eligibility criteria. This application is for provider distribution use only.

Instructions: This application is for the Bridges Rental Assistance Program (“Bridges”) only. Read the instructions for each section and answer all required questions. Incomplete applications will slow processing and may be returned. Once completed, please give this form to your local Housing Agency. Do not send it to the Minnesota Housing Finance Agency.

Housing Choice Voucher Requirement
To receive Bridges rental assistance, the applicant must also apply for a Section 8 Housing Choice Voucher. If the waiting list is currently closed, you must apply as soon as the waiting list opens and provide evidence of your application. Failure to do so will result in termination from Bridges, and you will no longer receive a rental subsidy.

Have you applied for a Section 8 Housing Choice Voucher?	      
 	YES – Complete the application information below.   
      	     	
Housing Authority Name	Date of Application	
  
 	NO – The waiting list is closed. The anticipated date the waiting list will open is      . 
	Do you understand that you must apply as soon as the waiting list opens, even if you have a Bridges voucher?   YES   NO

Personal Information	
     	     	
Name	Street Address (if applicable)	
     	                                      	     	        	     	
City	State	Zip Code	County	
     	      	     	
Home Phone 	Work Phone	Email (optional)	

Extent of homelessness prior to program intake:  
	Not homeless		First time homeless		Second or third time homeless	
	Long-term homeless (homeless for 12 or more consecutive months four times in the last three years)	

Living Situation Prior to Program Intake	
	Emergency shelter		Jail, prison, correctional facility, supervised release		Nursing home	
	Transitional housing		Board and lodge		Group home or foster care	
	Permanent supportive housing		Hotel/motel without voucher		Place not meant for habitation	
	Psychiatric facility or hospital		Living with family		Do not know	
	Hospital (non-psychiatric)		Living with friends		Refused	
	Substance abuse treatment or detox		Rental house/apartment		Other:      	

Barriers to Housing	
What barriers to housing do you face? Select all that apply:	
	Low (A score of 600 or below) or no credit	
	An eviction or unlawful detainer in the past three years	
	A criminal record	
	Negative landlord reference	
	Outstanding debt to a landlord or utility company	
	Unknown or not provided	

Emergency Contact 	
Name:	     	
Address:	     	
Phone:	     	Relationship	     	
Case Manager (if applicable)	
Agency:      	
Name:      	Phone:      	
Address:      	
Crisis Assistance Organization	
Agency:      	Phone:      	

Household Information	
Family Status (check all that apply): 	
	Head of household or spouse is 62 or older or disabled		Another family member is handicapped or disabled	
	Head of household or spouse is handicapped or disabled		None of the options	
Marital Status: 	
	Married		Unmarried		Separated		Divorced	

List the head of household and all other individual(s) who will be residing in the unit. Include the relationship of each family member to the head of household.	
Full Name	Relationship	Birthdate	Age	Gender 
(male; female; non-binary; other)	Social Security Number	
     	HEAD 	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	

You are not required to provide race and ethnicity information 
but supplying it will help with monitoring and determining compliance with civil rights laws.	
Race of Head of Household 
(select all that apply)	Ethnicity of Head of Household
Hispanic, Latinx, or 
Spanish Origin 
(select all that apply)	
	American Indian – Anishinaabe/Ojibwe		Black – African American (family has been in the United States for multiple generations)		Hispanic/Latinx – Mexican	
	American Indian – Dakota/Lakota				Hispanic/Latinx – Puerto Rican	
					Hispanic/Latinx – Cuban	
	American Indian – Other North American Origin/Tribal Affiliation		Black – Somali		Hispanic/Latinx – South or Central American	
			Black – Ethiopian		Hispanic/Latinx – Spanish Origin	
	American Indian – Central or South American Origin		Black – Other		Hispanic/Latinx – Other	
	American Indian – Other		Pacific Islander                           		Not Hispanic/Latinx (only select if none of the other ethnicity categories are selected)	
	Asian – Hmong		White – European			
	Asian – Indian		White – Middle Eastern or North African		Choose Not to Provide (only select if none of the other ethnicity categories are selected)	
	Asian – Chinese		White – Other			
	Asian – Vietnamese		Some Other Race			
	Asian – Other		Choose Not to Provide (only select if none of the other race categories are selected)			

Income Information
Include income for all household members aged 18 and over. Income eligibility will be recertified annually. You are responsible for immediately notifying your local Housing Agency, in writing, if your income changes at any time while receiving assistance.  
YES	NO		
		1.	Do you work full-time, part-time, or seasonally?	
		2.	Do you expect to work for any period during the next year?	
		3.	Do you work for cash?	
		4.	Do you expect a leave of absence from work due to lay-off, medical, maternity, or military leave?	
		5.	Do you receive or expect to receive unemployment benefits?	
		6.	Do you receive or expect to receive child support?	
		7.	Are you entitled to child support that you are not receiving?	
		8.	Do you receive or expect to receive alimony?	
		9.	Are you entitled to alimony that you are not receiving?	
		10.	Do you receive or expect to receive public assistance (TANF, MFIP, GA, FGA)?	
		11.	Do you receive or expect to receive Social Security benefits (SSI, MSA, SSDI, RSDI)?	
		12.	Do you receive or expect to receive income from a pension or annuity?	
		13.	Do you receive or expect to receive regular contributions from organizations or from individuals not living with you?	
		14.	Do you receive income from assets, including interest on checking or savings accounts, interest and dividends from certificates of deposit, income or interest from stocks or bonds or income from rental property?	
		15.	Do you own real estate or any asset for which you receive no income (checking account, cash)?	
		16.	Have you sold or given away real property or other assets (including cash) for less than their fair market value during the past two years? If yes, when      ; Amount      . Type of Asset      .	

For each YES above, provide income details below. Add additional pages, if necessary, as well as the name and address of employers. Be sure to list gross income (pre-tax income) for wages, Social Security, and Medicare. 
# (1-16 above)	Explanation of Income	Monthly Income Amount	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
				Total 	     	

Employment	
Name and address of current employer, if applicable:
     	Length of employment:
     	
Supervisor’s name:
     	Supervisor’s phone number:
     	
Name and address of current employer, if applicable:
     	Length of employment:
     	
Supervisor’s name:
     	Supervisor’s phone number:
     	

Assets
All household members’ assets must be included below. 
Bank or Agency Name	Type of Account	Account Number	Balance	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
You may be required to provide evidence of income and assets including:
•	Benefit award letters from Social Security, Minnesota Supplemental Aid, General Assistance, etc. 
•	Payroll check stubs showing hours worked and rate of pay (provide, at a minimum, one month)
•	Copy of a recent bank statement showing the account balance and interest rate 
•	Any other documentation of income and assets that may be available 

Applicant Certification 
The application must be filled out completely and signed by the applicant and all other adults 18 or older living in the household.

With my signature below, I verify that:
•	I have provided true and correct information on this application, to the best of my knowledge and belief.
•	I have read and understand the information contained on the Government Data Practices Act Statement and Authorization to Obtain Information and acknowledge so by signing said form (attached).
•	Assistance through the Bridges Rental Assistance Program is temporary and will continue only until Section 8 assistance or another permanent housing subsidy is obtained.

	     	
Head of Household’s Signature	Date	
	     	
18+ Household Member’s Signature	Date	
	     	
18+ Household Member’s Signature	Date	
	     	
18+ Household Member’s Signature	Date	
	     	
18+ Household Member’s Signature	Date	

Housing Provider Use Only: 
Application Approved:  YES      NO
Date the applicant was referred to the waiting list, or if there is no waiting list, the date the applicant’s housing search started       (this date will be added to the voucher when the first payment is initiated) If referred from the Coordinated Entry Priority List use the date the housing search started.