Community Action Board of Santa Cruz County, Inc.

The Shelter Project 501 Soquel Ave Suite E Santa Cruz, CA 95062 Phone (831) 457-1741 ext. 152, Fax (831) 457-0617 www.cabinc.org

Risk of Homelessness:
Indicate all of the applicable risk factors in the tables below. Documentation of risk factors is required. If you have evidence of these risk factors, please attach any relevant documentation. Priority Risk Factors: Yes No Yes No Yes Yes No No

Eviction within 2 weeks Discharge within 2 weeks from institution where you have resided for 6 months or more Living in housing that has been condemned Sudden and significant loss of income

Secondary Risk Factors: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No

Household with minor children facing eviction Sudden and significant increase in utility costs Mental health or substance abuse issues Physical disabilities and other chronic health issues, including HIV/AIDS Severe Housing cost burden (greater that 50% income for housing costs) Eviction from public or assisted housing Homeless in last 12 months Farm worker Housing instability, demonstrated by a history of homeless or repeated moves over last two years Young head of household (under 25) Current or past involvement with child welfare, including foster care Pending foreclosure of rental housing Raising a child under two Missing two or more appointments with a caseworker Current domestic violence Extremely low income (less than 30% median family income) High overcrowding (number of persons in unit exceeds health/ safety standards) and/ or living doubled up with relatives or friends Past institutional care (prison, treatment facility, hospital) Recent traumatic life event, such as death of spouse or primary care provider Credit problems that preclude obtaining housing Significant medical debt Other (please specify) __________________________________________________ ____________________________________________________________________