Entered in DB_____
Home Share Now
105 North Main Street, Suite 103; Barre, Vermont 05641
(802)479-8544
I seek housing ___ I have a home to share____ Number of people in the household_____
Full Name:
____________________________________________________________
Full Name (if spouse, partner, or child will also be participating)
____________________________________________________________
Name of Person filling out this form (if other than participant) & Relationship to Participant
__________________________________________________________________
Mailing Address:
____________________________________________________________
_________________________
City
____________
State
Home Phone: ___________________
________________
Zip Code
Work Phone: _____________________
Cell Phone: _____________________ Email Address: _________________________
Date of Birth: ____/___/____
Age: ____
Sex: F / M
Date of Birth: ___/____/____
Age: ____
Sex: F / M
Will you live with a Male ___ Female ___ Couple___ Children___
Do you smoke? Y / N
Will you live with a smoker? Y / N
Do you have pets? Y / N What kind? ________ Will you live with someone who has pets? Y / N
Do you drive? Y / N
Do you own a car? Y / N
Do you need a driver? Y / N
Are you seeking a home? Where would you like to live? __________________________
What kind of services can you provide to the home provider? (some examples: transport, cooking,
cleaning, yard work)___________________________________________________
_____________________________________________________________
What could you contribute to household expenses per month? $____________
Do you have a home to share? Are you looking for services (i.e. cooking, yard work,
companionship) Y / N
Do you require a contribution toward household expenses? Y / N Amount? $ _________
[Edited 02/02/2016]
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For reporting and statistical purposes, our funders require that we ask the following:
Annual Income (before taxes): _______________
Do you have a disability? If yes, please explain: ______________________________
Are you insured via Green Mountain Care? Y / N
Race (please choose one):
__White
__ Hispanic
__Black/African American
Are you a Veteran? Y/N
___ Asian/ Pacific Islander
___ American Indian / Alaskan Native
Have you ever been convicted of a crime? Y / N Are criminal charges pending against you? Y / N
Do you have any motor vehicle violations? Y / N
Have you ever been evicted/Is your home in foreclosure? Y / N
How did you hear about Home Share Now? _________________________________
Would you like to receive email updates from Home Share Now? Y / N
Home Share Now has a match fee due at the time of each final match. The fee is
based on a sliding scale, between $100 and $500 (payment plans can be made).
Have you:
______ answered all questions on your application; and
______ completed the reference sheet?
I hereby acknowledge that all the information I have given in this application is true and
complete to the best of my knowledge and belief. I authorize Home Share Now to check
references and to verify any information in this application. I understand that providing any
false or misleading information will make me ineligible for the services of Home Share Now.
Participant Signature: ________________________
Date: ________________
Co-Participant Signature: _____________________
Date: ________________
Home Share Now abides by and promotes Federal and Vermont Fair housing laws and does not discriminate based on race, color, religion, national
origin, age, sex, disability or handicap, sexual orientation, gender identity, presence of minor children, receipt of public assistance, or marital status.
[Edited 02/02/2016]
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Home Share Now–References
Participant _____________________________
Date_________________
Please notify all of your references that we will be calling them. Also
make sure that we will be able to reach them at the number you give.
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


Home Providers: Please provide 4 personal references and 1 employment
reference if applicable.
Home Seekers: Please provide 1 employment reference, 1 housing reference, and 3
personal references.
References should be people who really know you. The references should cover a
span of at least five years to the present.
We require references from a variety of backgrounds. For example: roommates,
co-workers, friends, neighbors, or family members.
1. Current Employment Reference
Reference Name & Name of Business
______________________________________________________________
Phone Numbers: Day______________________ Night _____________________
Address __________________________________________________________
Dates worked for them________________________________________________
2. (Home Seekers Only) Most Recent Housing (landlord) Reference
Reference Name ___________________________________________________
Phone Numbers: Day______________________ Night _____________________
Address _________________________________________________________
Dates rented from them_______________________________________________
3. Personal Reference Name ___________________________________________
Phone Numbers: Day______________________ Night _____________________
Address _________________________________________________________
How do they know you?________________ How long have they known you? ________
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4. Personal Reference Name ___________________________________________
Phone Numbers: Day______________________ Night _____________________
Address _________________________________________________________
How do they know you?_______________How long have they known you? _________
5. Personal Reference Name ___________________________________________
Phone Numbers: Day______________________ Night _____________________
Address _________________________________________________________
How do they know you?_______________How long have they known you? _________
6. Personal Reference Name ___________________________________________
Phone Numbers: Day______________________ Night _____________________
Address _________________________________________________________
How do they know you?_______________How long have they known you? _________
Please return this with your enrollment form
[Edited 02/02/2016]
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