PALACE MOBILE HOME PARK

727 289-7020 

Specialized Housing for Sex Offenders in St. Petersburg, Florida


PALACE MOBLE HOME PARK

R2 Property

2500- 54th Avenue No Ste 100-B

St Petersburg, Florida 33714

Office 727-289-7020     Fax: 727-954-7090

 

 

INTAKE INFORMATION /  WAIVER FORM
 
NAME:__________________________________________________


DATE:______________  EOS:_____________DC#_______________

Date of Birth:______________ Marital Status:   M  S  D         

Are You a U.S. Citizen:  NO / YES 


Social Security Number:_____________________   Veteran:  NO  / YES

Home Address: ________________________________________________________________


Phone/Cell Number:_________________________

Receiving any public assistance:  NO / YES          If Yes, What type of benefits (Circle appropriate response below):


 Food Stamps       Medicaid     SSI/SSDI      VA  Benefits       Wages     

Are you taking any medication(s)?  NO / YES  

IF YES, list any medications in the space provided:
_______________________________________________________________________________________________

Any history of alcohol abuse, drug abuse, or anger management issues:  NO / YES            If YES, explain below:

_____________________________________________________________________________________________


Can the applicant live amicable with others:  NO / YES     Any known disabilities or special needs:  NO / YES

If YES, list any disabilities and/or special needs:_______________________________________________________

Can applicant care for himself:  NO / YES

Name of emergency contact:______________________________________  Phone Number:_________________

Address of emergency contact:________________________________________________________

Relationship of emergency contact to the resident: ___________________________________________________

Highest education level completed: ___________________________ 

Past or Current Employer: ________________________________________________________________

Do you have a checking or savings account?  NO / YES


  Bank Name:___________________________________

If incarcerated, your classification officers name:


_________________________Phone Number:________________

Probation/parole officer/caseworker name:


______________________________ Phone Number:_______________


CRD?  (Circle One)  NO / YES     

 

STANDARD UNIT COSTS


 Application Fee…………………… (must be sent with application)….…… .....  $  200.00  (non-refundable)

 

 Monthly Fee (First two months and last is minimum in advance.) (elec. Not included)     $ 1050.00

 

TOTAL DUE TO SECURE RESIDENCY……………….…………………..    $ 1,325.00

WE ACCEPT CREDIT AND DEBIT CARDS, MONEY ORDERS AND CHECKS

 

Contact Persons For Fee Information:

Doug Baldwin                                           Charles Milczarek  dbaldwin@palacemhp.com                      cmilczarek49@palacemhp.com

 

 

When sending money contact the above listed person with the senders name, address, phone number, amount sent, the company sent through, and the reference number of transaction.                                                                                                               

 

APPLICANT ACKNOWLEDGEMENT AND WAIVER

 

                      Applicant will review the information and the following statement before admission.

 

“I have been advised that the Palace Mobile Home Park, offers low-cost housing to those looking to reside in

a safe drug and violent free community.  I understand that my stay here depends upon my effort and

desire to improve my life.  I agree to comply with all of the rules and regulations set forth by PMHP

and all staff members.  I understand that non-compliance with any rule and/or regulation may

Result in immediate expulsion from the premises without any prior notice.

I DO HEREBY WAIVE ANY AND ALL TENANT RIGHTS.”

 

          

            _________________________________________                                      Date:__________________

            Signature of Applicant

 

            _________________________________________

            Printed Name of Applicant

 

            _________________________________________                                      Date:__________________

            Signature of Witness

 

            _________________________________________

            Printed Name of Witness

 

            Rev:8-31-15Type your paragraph here.