Housing Application — D4 Strategic Holdings LLC

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Please complete all sections. Print clearly in ink. Return completed application to D4 management.

1. Personal Information

Full Legal Name:

Date of Birth:

Phone Number:

Email Address:

Current Address:

City:

State:

ZIP:

2. Current Living Situation

Check the option that best describes your current situation:

Currently without housing Staying in a shelter Temporary housing / couch surfing Living with family Currently renting (need to relocate) Transitional housing program Other

If other, explain:

3. Income & Benefits

Check all that apply:

SSI / Social Security SSDI SNAP / Food Assistance Employed — Full-time Employed — Part-time Seeking employment Unable to work Retired Other benefits No income/benefits

Monthly Income (approx):

4. Reason for Seeking Housing

5. Emergency Contact

Contact Name:

Phone:

Relationship:

6. Additional Information

Any medical needs, special requirements, or other information:

Applicant Agreement: I certify that the information provided is true and complete to the best of my knowledge. I understand that providing false information may result in denial or termination of housing. I authorize D4 Strategic Holdings LLC to verify the information provided. I have read and agree to the House Rules and Terms of Residency.

Applicant Signature:

Date: