* Indicates a required field.
First Applicant's Name: * Date of Birth: *
Second Applicant's Name: Date of Birth:
Marital Status: * SingleMarriedPartneredDivorcedWidowed
Method of Payment: * Private PayMedicaid (Do you currently receive HCBS benefits?)
Do you currently: * OwnRentLive in a retirement communityLive with family
How soon are you contemplating a move? * ASAP3-6 months6-12 months1-2 yearsUnknown
Do you drive? * YesNo Do you own a car? *YesNo
Do you own a pet? * YesNo If so, what kind?
Do you currently receive housing assistance? (i.e. Section 8) * YesNo
Do you currently live in subsidized housing? * YesNo
How did you hear about Golden West?
Alternative Contact: Relationship:
Please list any special apartment requirements below. Keep in mind that limited preferences can prolong the waiting time.
Please type the code below.