FSS Self-Survey and Application
FSS Self-Survey and Application

Self-Survey and Application
Please provide us with the following information, which will be kept confidential

Name: *

Main phone #: *

Address: *

Alternate phone #:

Apt #:



City/Town: * 

Do you have internet access?

No Yes

Zip Code: *

Email Address:



  1. How many people are in your household?*  Adults Children

  2. Does anyone in your household have a disability? Yes      No

  3. Do you currently have Section 8 Voucher Assistance?*
     No, If no, you are not eligible for the FSS program. Do not submit the application form.
    Yes, If yes, please provide Name, City & State of the Housing Authority/Community Agency providing your rental assistance:

  4. What type(s) of income/benefits does your household receive? (Complete all that apply)

    Self-Employment/Own my own business (state type of business)

    Yearly Gross Income from Self-Employment/Business:


    Hours per week? Employer Name & City:

    Position/Job Title?

    Benefits from work? (CTRL + Click to select multiple options)


  5. What is the best way to reach you? Phone E-mail Regular Mail

    If by phone, when is the best time to call?

    May we call you at work? When?

  6. Highest Grade Completed or Diploma/GED?*:

    City/State    or Country 

  7. Is Child Care needed for you to work or pursue educational program?

    What type of care needed? All Day Mornings Afternoons Evenings

  8. Do you currently attend any education or training programs? Yes No

    If yes, where are you studying?

    When did you begin? When will you finish?

  9. Have you ever participated in a formal job training program? Yes No

    If yes, please explain:

  10. What kind of experiences / services do you need to become self-sufficient? (CTRL + Click to select multiple options)


  1. How did you hear about the Family Self-Sufficiency Program?

  2. Why do you want to participate in the Family Self-Sufficiency Program?

  3. The FSS Program requires monthly contact with FSS Coordinator and participation in FSS events and workshops. Will you be able to meet this requirement?*             Yes No

  4. The FFS Program requires that you live in Alameda during the first year of the program contract. Will you be able to meet this requirement?*  Yes No

  5. Are you interested in homeownership? Yes No

  6. Would you like to be added to our e-mail? Yes No


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