Native American Supportive Housing in Akwesasne
General Contact Information
Name: ___________________________________________________________
Current Address: ___________________________________________________
Current Phone Number: ___________________________________
E-Mail Address: __________________________________________
My current living situation (please describe in as much detail as possible):
____________________________________________________________________
____________________________________________________________________
Please check any of the following that apply to your situation:
o I am currently without housing and I consider myself homeless.
o I am currently “couch surfing” because I don’t have any other choice.
o I am currently living in overcrowded conditions (i.e. with family or friends).
o I am living in substandard housing.
o I feel I cannot afford the housing I am currently living in.
o I am not sure if I consider myself homeless, but feel I could qualify for assistance.
o I typically jump from one place to another.
o Other: ____________________________________________________________
_____ If you feel you may not qualify for supportive housing voucher at this time, but
would like to keep updated on the progress of this specialized program, please check
here.
_____ I am interested in being put on the waiting list for veteran’s supportive housing.
If you are not a veteran but know of someone who could be assisted with safe
and affordable housing for Native American Veterans, please provide this
information to them.
