HomeShare A County of Ventura Program

Home Seeker Application PLEASE PRINT CLEARLY

646 County Square Drive, Suite 100, Ventura, CA 93003 Tel 805-477-7324 / Fax 805-477-7312

Personal Information

Last Name First Name

Address City Zip

Phone 1 Phone 2 Email

☐Work ☐Home ☐Pager ☐Work ☐Home ☐Pager

☐Message ☐Cell ☐Message ☐Cell

SSN Gender DOB

How did you hear of us? Please indicate if you are a # in Family

☐Newspaper ☐Senior Center ☐Senior

☐HomeShare Client ☐Government Agency ☐Single Parent # of Adults

☐Friend ☐Non-Profit ☐Veteran

☐Job ☐Internet ☐Student # of Children

☐Brochure ☐Presentation ☐Head of Household

☐Couple

Preferred Language

Housing Needs

# seeking for Do you smoke? Will you live with a smoker? ☐ Regularly ☐ Inside ☐ Yes ☐ Outside Only

☐ Never ☐ Outside ☐ No

Do you have pets?

Comment Will live with pets?

Comment

☐ Yes ☐ Yes

☐ No ☐ No

Have Car? Driver License #

☐ Yes

☐ No

Home Seeker Application PLEASE PRINT CLEARLY

2

Housing Needs

Able to Pay Dwelling Type(s) Cities Min Bedrooms Needed ☐1 BR ☐Studio $ Interested in: ☐Camarillo ☐Both

☐Townhouse ☐Fillmore Willing to Share ☐Yes ☐No ☐Condo ☐Moorpark

Current Rent ☐House ☐Oak View Bathroom ☐Private Only $ ☐Apartment ☐Oxnard ☐Willing to Share

☐Mobil Home ☐Piru Need Furnished Room ☐Yes ☐No ☐Either ☐Granny Flat ☐Port Hueneme Have Furniture ☐Yes ☐No

Was Paying ☐Santa Paula

$ ☐Simi Valley Need Storage ☐Yes ☐No ☐Thousand Oaks

☐Ventura Service Exchange Desired ☐Yes ☐No

Willing to live with more than ☐Yes ☐No If Yes: Type of Exchange ☐Flexible 1 person? ☐Set

Need Public Transportation Access ☐Yes ☐No ☐Childcare ☐Handyman/Garden

Need Wheelchair Access ☐Yes ☐No ☐Evening

Need Parking ☐None

Need internet access ☐Yes ☐No ☐Garage ☐On Street

Housing Situation

Housing Status Homeless/At Risk Situation

☐At-Risk ☐3 day notice ☐Job hours reduced

☐Have Own Place ☐30 day notice ☐Landlord Died

☐Homeless ☐60 day notice ☐Lease expired

☐Sharing ☐Accessibility Issues because of disability ☐Lost job ☐Car ☐Motel

Housing Assistance ☐Choose to stay in motel and can afford ☐No child support Currently Received: ☐Commute Issues ☐Not getting along with family or housemate

☐Section 8 ☐Debt level too high ☐Overcrowded

☐CalWORKS ☐Domestic Violence ☐Owner/housemate giving up property

☐HSA Rapid Rehousing ☐Drugs/Alcohol in home ☐Provider needs the room

☐RAIN ☐Emancipating from Foster Care ☐Rehab program

☐Many Mansions ☐Fire ☐Relationship ending

☐HA Waitlisted ☐Foreclosure ☐Relocation to area

☐Other – please list ☐Friend/Family ☐Rent Increase ☐Health Care Costs ☐Shelter ☐Hospital ☐Street ☐House being rehabbed ☐Substandard ☐House was sold ☐Too expensive ☐Housemates stealing property ☐Transitional housing ended ☐Income reduced and cannot afford rent ☐None of the above

Home Seeker Application PLEASE PRINT CLEARLY

3

Employment

Employer City Years at Job

Job Title

Employer City Years at Job

Job Title

Income Income Source

References

References should be from past or present roommates, landlords, employers or co-workers.

Personal references may NOT be family members, significant others, boy/girl friends, spouses or life-partners.

Personal references known at least 5 years may be substituted for landlord or professional references at the discretion of HomeShare. Please notify your references that HomeShare will be calling them. Please understand that if you have trouble reaching them, we will have the same trouble, and your application may be delayed.

Professional Reference

Name Relationship

Phone How long have they known you

Previous Landlord

Name Relationship

Phone How long have they known you

Personal Reference

Name Relationship

Phone How long have they known you

Emergency Contact Information

Emergency Contact 1

Name Relationship

Phone Address

Emergency Contact 2

Name Relationship

Phone Address

Home Seeker Application PLEASE PRINT CLEARLY

4

Personal

Hobbies

Reason Seeking HomeShare Match

Ideal HomeShare

Special Qualities

Preferences

I would consider a housemate that is (check if yes):

☐female ☐male ☐younger ☐older ☐different race or ethnicity ☐different religion

☐identifies as LGBTQ ☐from another country ☐ a non-native English speaker ☐family

☐ single parent with child

Race (voluntary – for statistical purposes only)

☐American Indian or Alaskan Native ☐Guamanian ☐Other Pacific Islander

☐Asian Indian ☐Hawaiian ☐Other Race

☐Black or African American ☐Japanese ☐Samoan

☐Cambodian ☐Korean ☐Vietnamese

☐Chinese ☐Laotian ☐White

☐Decline to State ☐Multiple Race

☐Filipino ☐Other Asian

Ethnicity

☐Not Hispanic/Latino ☐Hispanic/Latino ☐Decline to State

Home Seeker Application PLEASE PRINT CLEARLY

5

I hereby acknowledge that all the information I have given in this application is true and complete to the best of my

knowledge. I consent to having HomeShare check references and conduct a background check. I understand that the

information my references provide will not be disclosed to me as part of the screening process. I understand that false,

misleading or incomplete information may make me ineligible to receive HomeShare services.

Signature Date

Office use

Office Intake Date Counselor

Health

☐No Concerns ☐Medications Comments

☐Read First

☐Health or Substance Abuse Issue ☐Disability Comments

☐Must Disclose

☐Do Not Refer or Activate ☐Substance Abuse Comments

Background Check/Disclosure

☐Felony Conviction Disclosures

☐Misdemeanor Conviction

☐Parole/Probation

☐Client has been granted a restraining order

Confidential Narrative

NOTES:

HomeShare A County of Ventura Program

Program Exit Guidelines Ventura County HomeShare (“HomeShare”) is a non-discriminatory, equal opportunity, shared housing program. We

strive to serve Ventura County residents regardless of age, race, religion, sexual preference, or socio-economic status. As

part of this program, HomeShare requires everyone to provide copies of identification and Social Security cards, provide

references and pass a criminal background check. If a person is having trouble meeting any of these requirements, he or

she should talk with staff to discuss alternatives.

In the case a participant becomes inactive, notification will be mailed to the address of record. Below is a list of reasons

a participant may no longer receive services and be made “Inactive” in the program:

• Falsifying information

• Damage done to HomeShare property, the property of a home provider, or the property of a home seeker

• Inappropriate behavior or boundaries toward a staff or program participant

• Crimes or illegal activity committed while in the program

• Non—compliance with substance abuse or mental health treatment

• Unable to contact a non-matched program participant by phone, email, and mail after 3 months of trying

• Failure to comply with services or rent contractually agreed upon by the home seeker and home provider

• If the home becomes uninhabitable or not fit for home sharing

Staff exercises their right to exit anyone from the program if they fall into one of the above categories. This list is not

comprehensive and someone may be made inactive for another reason. In addition, staff may use discretion at any time

and allow a participant to stay in the program, based on the nature and context of the offense.

I, _________________________________________________, have read and understand the above guidelines. I

acknowledge that anything listed above may result in my dismissal from the program, and that I am responsible for my

own behavior toward staff, volunteers and fellow program participants.

Participant: __________________________________________ Date:_____________________

HomeShare Staff: _____________________________________ Date:_____________________

PARTICIPATION AGREEMENT AND RELEASE

You have elected to participate in Home Share, (the “Program”), a program of the Ventura County Area Agency on Aging (the “Agency”). As a condition of participating in the Program, you acknowledge and agree to the following: (a) that although the Program has introduced you a participant(s) in the Program

regarding a possible housing arrangement, NODIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, REPRESENTATIVES, AGENTS, OR CONTRACTORS OF THE PROGRAM OR THE AGENCY HAVE MADE ANY REPRESENTATIONS OR WARRANTY ABOUT ANY SUCH PARTICIPANT(S) IN THE PROGRAM, INCLUDING NO REPRESENTATION OR WARRANTY REGARDING THE ACCURACY OF ANY INFORMATION FURNISHED BY SUCH PARTICIPANT(S), OR THE ABILITY OF ANY SUCH PARTICIPANT(S) TO PERFORM HIS, HER, OR THEIR OBLIGATIONS IN CONNECTION WITH SUCH POSSIBLE HOUSING ARRANGEMENT OR THE SUITABILITY OF ANY ROOM OR OTHER PREMISES TO BE RENTED BY A PARTICIPANT;

(b) that any housing arrangement you enter into will be voluntary; (c) that any decisions in the selection and/or acceptance or rejection of a housing

arrangement will be independent decisions made solely by me and the other participant(s) and that no one from the Program or the Agency had any part in such decisions;

(d) that no one from the Program or the Agency, nor any directors, officers, employees, representatives, agents or contractors of the Program or the Agency, have made any expressed or implied guarantees or warranties regarding the suitability of any housing arrangement entered into by me or the success of such housing arrangements or the ability of any participant to pay rent;

(e) that when a participant calls in for housing referrals, names of participants to contact may not always be available;

(f) that there is no guarantee that a shared housing placement will be arranged; (g) that the Program staff and volunteers may conduct background checks or other

investigations on any participant and I consent to such background checks and investigations on me;

(h) that the Program staff and volunteers may check any references provided by a participant and the undersigned consents to the checking of references;

(i) that some information provided by me might be subject to disclosure to the public under the Public Records Act;

(j) that it is your sole responsibility to determine the suitability of any potential housemate and to check the references of any potential housemate and to determine the legality of renting any room in your home and to determine the necessity and extent of any insurance coverage;

(k) that it is the sole responsibility of a potential housemate to determine if the landlord is agreeable to a Share Program arrangement;

(l) that if you are the landlord participant, you are solely responsible for collecting rent and that the Program, the Authority or the Agency will not be liable for any failure to pay rent.

Release and indemnification: In consideration of my participating in the Program, I, on behalf of myself, my next of kin and personal representatives, hold harmless, release, waive and discharge the Program, the Agency, and each of their officers, directors, representatives, departments, contractors, subcontractors, employees, volunteers, and agents (the “Releasees”) from all liability due to the active or passive negligence of any Releasee or otherwise in any way arising from or related to the Program. I further agree that except in the event of gross negligence or willful misconduct by a Releasee (for which this release shall not apply), I shall bring no claims, demands or litigation of any kind against any Releasees, for any economic or non-economic loss or damage due to mental distress, bodily injury, death or property damage sustained by me arising from or in relation to the Program. Notwithstanding the exclusion of gross negligence or intentional misconduct, I acknowledge that all statutory immunities shall still apply to any Releasee. I also agree to indemnify, defend and hold harmless the Releasees from (i) any liability, demand, damage, claim, cost, loss or expense (including attorney’s fees) they may incur because of any lack of capacity or defect in capacity in executing this agreement and (ii) any liability, demand, damage, claim, cost, loss or expense (including attorney’s fees) in any way arising from or related to my participation in the Program, except that such indemnification shall not apply to the fraud, gross negligence or intentional misconduct of such Release.

I HEREBY CERTIFY THAT THE INFORMATION GIVEN ON THE APPLICATION IS TRUE, THAT SUCH INFORMATION MAY BE VERIFIED, AND THAT THIS AGREEMENT HAS BEEN VOLUNTARILY SIGNED, READ AND UNDERSTOOD. I UNDERSTAND THAT I AM GIVING UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES IN CASE OF INJURY, DEATH OR PROPERTY DAMAGE. SIGNATURE:_______________________ DATE: ____________________ PRINT NAME:_____________________________ RESIDENT OF:____________________________ THIS IS A RELEASE-READ BEFORE SIGNING

INTEREST FORM

Name

Provider

Seeker

Date

Phone

Please check below if you would like to have a VCAAA representative contact you with information about other Agency or Community services. VCAAA Services:

Elder Help

Chore Services

Homemaker

Home Modifications

Personal Care

Respite

Fall Prevention Classes

Matter of Balance

Stepping On Class

Tai Chi: Moving for Better Balance

Family Caregiver Assistance

Housing

Health Insurance Counseling and Advocacy Program (HICAP)

Information and Assistance

Long Term Care Services

MSSP – Case Management

Senior Support Line

Senior Nutrition

Transportation

Other Community Services:

Adult Day Health Care

APS

Emergency Housing/Shelter Information

Grey Law

Gold Coast Veterans Foundation

HSA Homeless Services Resource List

Ombudsman

Support Groups

IHSS or other Caregiver

Other not listed above: