Grant Applicant Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you consent to a background check? *

Yes

No

Are you a US citizen or a legal permanent resident? *

Citizen

Legal Permanent Resident

I am not a US citizen or a legal permanent resident

Are you a U.S. military veteran? *

Yes

No

Will there be any other people living with you in this tiny home? *

Yes

No

Please select your profession: *

Active Duty Military

First Responders (Firefighters, Police Officers, Paramedics, EMT's, Search & Rescue)

Healthcare Workers / Caregivers

Public Service Workers (Social Workers, Child Protective Services, Public Health, Community Service, Nonprofit Employees)

Educators (PreK - 12th Grade Teachers, Special Education, School Counselors, School Administration)

Not Applicable/Retired

Other

Current Sources of Income (check all that apply) *

Employment

VA benefits

Social Security

Disability

Unemployment

Other

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Supervisors Phone Number:

(###)

###

####

Are you struggling with hardship? *

Low Income (Does your household income fall below the median income level for your area?)

Natural Disaster (Have you been affected by a natural disaster (e.g., hurricane, flood, wildfire, earthquake) in the past five years?)

Illness (Are you or an immediate family member dealing with a severe or chronic illness that has impacted your financial stability or housing situation?)

Aging out of Foster Care (Are you currently or did you previously age out of the foster care system?)

Disability (Do you have a physical or mental disability that affects your ability to work or maintain stable housing?)

Surviving Spouse of a Military Member or Public Protector (Are you the surviving spouse of a military member, firefighter, police officer, or other public protector who died in the line of duty?)

Domestic Violence (Have you been a victim of domestic violence that has affected your housing stability?)

Single Parent (Are you a single parent struggling to provide stable housing for your children?)

Job Loss (Do you have unemployment benefits statements, a termination letter, or proof of reduced hours?)

Eviction or Foreclosure (Do you have eviction notices, foreclosure documents, or a letter from a landlord?)

Substandard Housing (Do you have photographs, inspection reports, or a letter from a housing authority describing the conditions?)

Medical Debt (Do you have substantial medical debt that has impacted your ability to afford stable housing?)

Other

Are you willing to live long-term at Roots Collective Farm in Buckley, WA if selected for this program? *

Yes

No

Do you understand that the home must remain on the designated site and cannot be relocated without written permission from Operation Tiny Home *

Yes

No

Do you agree to maintain the home and use it as your primary, permanent residence? *

Yes

No

Do you understand that the home remains the property of Operation Tiny Home and will revert back to the organization when no longer needed? *

Yes

No

Waiver Statement *

Photo and Video Consent: Submission of your grant application authorizes Operation Tiny Home and our affiliates, agents and partners to use photographs, video or sound recordings of you. This is completely voluntary and up to you. Your consent to the use of the photographs, video and sound recordings and your image, likeness, appearance, and voice is forever. The photographs, video and sound recordings may be used for any educational and informational purposes whatsoever. You will not receive compensation for the use of your image, likeness, appearance, and voice now or in the future. I understand and agree.

Yes, I agree

No, I do not agree

Are you willing to sign a notarized affidavit confirming this information if selected? *

Yes

No