Home Providers Application Home Providers Step 1 of 9 11% Dear HomeShare Applicant, Thank you for your interest in HomeShare Kootenai County, Inc. We look forward to working with you to find a compatible home-mate! In order to participate, please be prepared to: Complete a Program Application, including contact information for three References who know you well Consent to a Criminal Background Check Complete an interview with a Match Ambassador Sign our Program Agreement and Waiver It can take up to seven business days to confirm acceptance into the program after the application is received and background checks are completed. HomeShare participants are matched on the basis of compatibility; it can take weeks or months to find a compatible match. The HomeShare Program does not provide emergency housing, and placement is not based upon vulnerability. HomeShare Kootenai County, Inc. cannot guarantee a match for any participant. You may contact us by email or phone regarding the status of your application, or with other questions: (208) 215-2269, or email@example.com MATCH FEE As a private, non-profit organization our fees are an important source of income for our program. There is no fee to apply. Only if we are successful in finding you a match do we charge the Home Provider a one-time match fee, which is due when the Match Agreement is signed. The Match Fee for the Home Provider is a one time payment in the amount of 25% of one month's rent. We will provide you a bill when your match fee is due. All fees are non-refundable. If your match should end unexpectedly within the first three months, your paid match fee will be credited in full toward your next match. Home Seekers will be charged a match fee of $35. Your InformationLegal Name(Required) First Last Maiden or Other Names Used Date of Birth(Required) Month Day Year AgeGender(Required) Female Male Non-Binary Prefer not to say With whom would you be comfortable sharing a home? Check all that apply(Required) Female Male Couple Parents with Children Any Primary PhoneAlternate PhoneBest Time for Us to Call to Schedule an InterviewMorningAfternoonEveningMailing Address Street Address Address Line 2 City State ZIP / Postal Code Email(Required) Housing History & PreferencesWhere is your home located? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you own your own home(Required) Yes No Will your landlord allow you to take in a housemate?(Required) Yes No Not Sure If you rent, please provide your landlord's name and phone number: If the home is a rental, the landlord must consent to additional occupants.What type of home do you live in?(Required) Apartment/Condo Single-Family Home Duplex/Multi-Plex Accessory Dwelling/Mother-in-Law Unit Mobile Home RV/Trailer Other Please describe location of room to rent (i.e., downstairs, upstairs, converted garage, etc.):(Required)Are you offering a private bedroom?(Required) Yes No What type of bathroom are you offering?(Required) Private Shared This home offers (check all that apply):(Required) Private Entry Laundry Facilities Parking Shared Bathroom Shared Kitchen Shared Living Area Storage Space Please list furniture provided (if any):Which type of HomeShare match are you interested in? (please select one)(Required) Rent Service Exchange Rent + Service Exchange Not Sure Rent Amount or Range(Required) Are utilities included in the rental price?(Required) Yes No Partially Non-refundable Deposit Refundable Deposit Please select all of the types of services that you would consider receiving (can select multiple): Companionship Cooking Errands Handy Person Housekeeping Shopping Transportation Yard Work Other How many hours of service would you be looking to receive per week?(Required) Does your home have stairs in it?(Required) Yes No Do you have pets?(Required) Yes No If you have pets, please number & typesAre you willing to live with pets?: Yes No Please check the box below if you have others living with you:(Required) Yes No Will this person / these people continue to live with you? Yes No Please list name(s), gender, age(s) of additional person(s)(Required)Others living with you over age of 18 will be subject to a criminal background check.Are you willing to share a home with someone who has children living with them? Yes No Where did you learn about HomeShare Kootenai County?Please select211AdvertisementSocial MediaWord of MouthHave you applied for, or been enrolled in, any HomeShare program before? Yes No Annual gross household income (Must include all sources of income):(Required)For reporting and statistical purposes only. This information will be kept confidential from a potential house-mate.What are your sources of income? Select all that apply(Required) Employment Family/Friends Alimony General Assistance Investments/Trusts Pension Real Estate Property Savings Social Security SSDI Student Loans VA Other Our funders require that we ask for the following information. This information will help determine that Kootenai County, Inc. does not discriminate in its services.What is your preferred language(Required) Do you speak any other languages? If so, please list here:Please select your race/national origin:(Required)Please SelectWhiteHispanicBlack/African AmericanAsian or other Pacific IslanderAmerican Indian/Alaskan NativeMulti-RacialPrefer not to sayPlease select your ethnicity:(Required)Please SelectHispanicNon-HispanicAre you a Veteran or Veteran Spouse?(Required) Yes No Veteran Spouse Health & ConditionsPlease select all of the following that are applicable to you (can select multiple):(Required) Chronic Disease Hard of Hearing Memory Loss Vision Loss Physically Disabled Fall Risk Mental Behavioral Health Trouble with Stairs Uses Cane Uses O2 (Oxygen) Uses Walker Uses Wheelchair None More Information Regarding ConditionsHave you had any injuries, falls, or hospitalizations within the last year?(Required) Yes No Do you currently need assistance with any ADLs? (Activities of Daily Living: bathing, dressing, taking medications, eating, toileting, transferring, etc.)(Required) Yes No Lifestyle This information is confidential and will not be shared, but can help you reflect on what is important to you in your space, routine, and lifestyle. It also helps us determine who might be a good match for you.Do you smoke cigarettes?(Required) Yes, outside the home only Yes, inside the home No Would you be ok with a housemate who smokes cigarettes?(Required) Yes No OK, if it's outside only Other Do you vape?(Required) Yes, outside the home only Yes, inside the home No Would you be ok with a housemate who vapes?(Required) Yes No OK, if it's outside only Other Do you drink alcohol(Required) Never Rarely Occasionally Frequently Would you be ok with a housemate who drinks alcohol?(Required) Yes No Other The following section is an opportunity for you to talk about your likes, dislikes, preferences, and values. This information is confidential and will not be shared, but can help you reflect on what is important to you in your space, routine, and lifestyle. It also helps us determine who might be a good match for you.Please describe your hobbies and interests:What are your sleep habits? Do you consider yourself an early bird or a night owl? Do you consider yourself introverted, extraverted, or somewhere in between? Would you like to share activities (eating meals together, watching TV, playing games, socializing) with a housemate?Is there anything you feel very strongly about (religion, politics, music, food, etc.)?Do you have any pet peeves that might be relevant to shared living (leaving lights on, not shutting doors, leaving the toilet seat up, etc.)?What do you consider to be your best qualities?Do you have any fire arms in your home??(Required) Yes No Would you be OK if a roommate brought fire arms in to your home??(Required) Yes No Background Check and References As part of our application process, we do a background check and a personal interview. HomeShare Kootenai County, Inc. asks for references in order for us to find the right person for you. Criminal history along does not determine eligibility for HomeShare. However, some crimes may be disqualifying. This information will be shared with home-mates. Please provide three references. Appropriate references include: supervisor, roommate, co-worker, friend, family, or relative who has lived with you. Do you have any pending criminal charges??(Required) Yes No Have you had any criminal convictions?(Required) Yes No If yes to any of these questions, please explain:Reference #1(Required) First Last Daytime Phone(Required)Years Known Relationship to Applicant Reference #2(Required) First Last Daytime Phone(Required)Years Known Relationship to Applicant Reference #3(Required) First Last Daytime Phone(Required)Years Known Relationship to Applicant State any other relevant information you would like our HomeShare team to know and consider ...Consent(Required) 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 understand that providing any false or misleading information will make me ineligible for the services of HomeShare Kootenai County, Inc.Receipt of HomeShare Kootenai County Inc. Program Agreement and Waiver: By signing below, you consent to the following statement: I have received the HomeShare Kootenai County Inc. "Program Agreement and Waiver" outlining the current program policies. I have either read it, or had it read to me carefully. I understand that this document has been prepared for the information/guidance of all HomeShare participants. I accept that, with time, the information may change as this Program Agreement and Waiver is under constant review. The undersigned wishes to apply for and participate in HomeShare Kootenai County’s Home Sharing Program (“Program”) on these terms: Acknowledgments and Agreements: a) HomeShare Kootenai County does not guarantee the accuracy, reliability, completeness, or usefulness of any information provided by other Program applicants, participants, their references or any other third parties, and that HomeShare Kootenai County has no obligation to verify or seek to verify the statements of Program applicants or participants; b) Although HomeShare Kootenai County may introduce me to a person(s) with whom a possible housing arrangement may be made, HomeShare Kootenai County does not make any promises, guarantees, or representations about the ability of any such person(s) to perform his or her obligations with such possible housing arrangement; c) Any decisions to enter into a housing arrangement, including selection of the other person(s), will be made solely by the undersigned and the other person(s) involved and that HomeShare Kootenai County has no part in such decision; d) HomeShare Kootenai County doesn’t endorse or advocate for and is not responsible for the conduct of any Program participant; e) HomeShare Kootenai County has not made any expressed or implied guarantee or warranties regarding the suitability of housing arrangements involving any particular individual or residence; regarding the condition of any housing; or regarding the success of any housing arrangement; f) When I call to check in for referrals, names of clients for me to contact may not always be available; g) I give permission for my references to be checked by Program applicants or HomeShare Kootenai County. If I enter into a home sharing arrangement, I give permission for my references, emergency contact person or advocate to be contacted; h) I give permission to HomeShare Kootenai County to conduct a criminal background search through Superior Court databases and a National Sex Offender database check, provided the information is available. I will provide additional information regarding my criminal background to HomeShare Kootenai County upon request. i) HomeShare Kootenai County cannot guarantee that a shared housing placement will be arranged; j) I understand that any housemate referrals given to me are confidential and not to be shared with others; k) HomeShare Kootenai County may decline or remove me from participation in the Program at its own discretion if I make false or misleading statements as part of the application process; if I fail to provide requested information about my criminal background; if I direct rude, threatening or inappropriate language or behavior at HomeShare Kootenai County staff, volunteers or clients; or for any other reason. l) HomeShare Kootenai County does not conduct credit checks on individuals for program participation, nor does the program have any income qualifications or restrictions for participation. However, we do require proof of income for the past 30 days from all home seekers to demonstrate general ability to pay rent. m) HomeShare Kootenai County, Inc. collects personal information from participants and other sources relevant to participant’s personal history, rental history, and criminal background history (collectively “Personal Information”). Participant authorizes HomeShare Kootenai County to release participant's Personal Information to potential matches, in order to provide transparency between the parties entering a home share agreement. Release of Personal Information will only be used only for purposes of determining appropriate services for participants. This Agreement includes waivers by me of possible legal rights and claims and my entry into the Agreement includes agreeing to this waiver and is consideration for my participation in the Program. Limitations of Liabilities and Acceptance of Risk: I acknowledge and agree that, to the maximum extent permitted by law, HomeShare Kootenai County will not be liable for any bodily, property, emotional distress, monetary, or other damages that I or any of my family members or other persons may suffer arising from my participation in the Program. I understand that my participation in the Program may involve living in a close residential setting with another person, and that it has inherent risks that may arise in a variety of ways, including but not limited to: condition of a residence, housemate making false or misleading statements on a Program application or in any agreement we sign, housemate’s failure to pay rent on time or in full, housemate’s disclosed or undisclosed financial, psychological, social, substance abuse issues, and/or exposure to communicable illness. I acknowledge and accept these risks. Waiver and Release of Claims: In consideration for my participation in the Program, I wave and release any and all claims against HomeShare Kootenai County, for any liability, loss, damages, claims, expenses and attorneys’ fees resulting from death or injury to my person, family, guests, or property, caused by or arising directly or indirectly from my participation in the Program, regardless of the cause and even if caused by negligence, whether passive or active. I agree that HomeShare Kootenai County is not responsible for any loss or damage resulting from my reliance on information or other content transmitted to or by any Program participants. I agree not to sue HomeShare Kootenai County on the basis of these waived and released claims. Indemnification: If HomeShare Kootenai County suffers any legal claims, liabilities, or costs due to my participation in the Program, including my behavior or the behavior of anyone for whom I am legally responsible, I will defend, indemnify and hold harmless HomeShare Kootenai County from and against all such claims. I will pay the cost of defense and the amount of the liability, if any, incurred by HomeShare Kootenai County, except and only to the extent that the liability is caused by the gross negligence or willful misconduct of HomeShare Kootenai County. Additional Agreements: I, the undersigned, acknowledge and agree that the decision to enter into a shared housing agreement with another HomeShare Program participant is my sole responsibility and that the responsibility to verify all information provided. I acknowledge that HomeShare Kootenai County has encouraged me to verify everything independently. I will inform HomeShare Kootenai County when a Home Sharing placement is made and when it ends. I agree to give HomeShare Kootenai County amendments to the Living Together Agreement. Statement of Non-Discrimination: HomeShare Kootenai County abides by the federal Fair Housing Act and the State of Idaho’s fair housing laws which prohibit discrimination in housing on the basis of race, color, religion, sex, national origin, ancestry, gender, disability, sexual orientation, marital status, or other protected characteristics. HomeShare Kootenai County does not refer applicants based on any of these preferences. If housemates will be sharing common or living areas of a house, the law permits a preference on the basis of sex or gender. Confidentiality: HomeShare Kootenai County will maintain confidentiality with regard to information set forth on the application or otherwise obtained through the application process. Subject to applicable laws, HomeShare Kootenai County will only use your information in connection with its operation of the Home Sharing Program, as deemed appropriate by HomeShare Kootenai County. Termination: I understand that this authorization may be withdrawn at any time by written notification except to the extent that action has already been taken, and that this authorization will otherwise automatically expire with the termination of my participation in the HomeShare Program. Definitions: For purposes of this agreement, “HomeShare Kootenai County” its affiliated entities, directors, officers, employees and agents. “Participant” means both applicants to the Program and those providing or sharing housing as a result of applying to the Program. “Participation” means all aspects of participation, including applying to the Program, providing housing to another person, and living in a housing obtained as a result of applying to the Program. Fees: HomeShare Kootenai County charges a modest match fee — but not until you are settled in a successful home sharing relationship. For the Home Provider, we charge a one-time match fee equal to 25% of the first month's rent. Home Seekers will be charged a fee of $35. This is a one-time fee for the life of the match. If your match should end unexpectedly within the first three months, your paid match fee will be credited in full toward your next match. Signature of Applicant(s) I declare all information furnished in this document is true to the best of my knowledge. I consent to the terms of participating in the Home Sharing Program in this agreement. I consent to verification of all information provided by me.Date MM slash DD slash YYYY Thank you for your application. You will be contacted by the HomeShare Match Ambassador for an interview. Note: You must check the box under "Consent" to see the Submit button. You will receive a copy of the Program Agreement and Waiver in your confirmation email.