Program Eligibility Please be truthful in your responses, you will need to verify all information 1.      Have you been assisted by COMPASS within the past 12 months? Select one: Yes No 2.      Submitting all your supporting documents can still result in you not being approved Select one: I understand, I will proceed No, I will not be wishing to proceed 3.      What is or has been your employment status? Select one: Employment (Full-time/Part-time/Sesaonal employment) VA Unemployment  SSI  Other (specify on next page) 4.      Is the eviction or disconnect scheduled to happen within the next 48 hours? Select one: Yes No 5.      To qualify for our assistance, you will need to be able to provide the following documents : Eviction, utilities disconnect, or late notice Household employment verification showing pay rate and hours (if unemployed, most previous paystubs from prior employment) A signed lease agreement Documents showing why you are unable to pay your rent or utilities this month (example; medical records, paystubs showing less hours, etc. Proof you can sustain the household the following month (example; new hire documentation, letter of pay increase, etc.) Identification for everyone in the household Ledger or statement of late balance from the landlord Will you be able to provide ALL of the documents listed above? Yes No 6.      Are you over 50 or under 50 years of age? Select one: Over 50 Under 50 7.      Is there at least one minor or pregnant adult at home? Select one: Yes No