Client Application--

Please complete and submit all three forms along with all documentation requested in order for our team to process your request. Applications that are not completed fully or documents not submitted will not be reviewed.

Date of Application:

Today's Date

Request Type:

Please select Workshop

Housing Matters Workshop Rent Wise Workshop

Initial Contact:

Other - Please Specify

Example: Mortgage, Fair Housing

Full Name: *

Prefix First Name Middle Name Last Name Suffix

Phone Number *

Please enter a valid phone number.

Email Address:

example@example.com

Current Address:

Street Address

Street Address Line 2

City State

Zip Code

Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Choose One:

Rent Own Other

County:

Current Living Situation:

How long at address?

Ex: 5 Months, 3 years, 10 years

Subsidized Housing?

Yes No

If Yes, Select One:

Section 8 Public Housing Other

Emergency Contact:

First Name Last Name

Emergency Contact Phone Number:

Please enter a valid phone number.

Relationship to you:

Number of Bedrooms in Home:

For Rental Assistance

Monthly Rent Amount:

For Rental Assistance

Please select Utility Bill(s) that assistance is needed for:

OPPD MUD Black Hills Mid-American Other

Please enter total amount requesting for Rental Assistance:

OPPD Account Number:

For Utility Assistance

MUD Account Number:

For Utility Assistance

Black Hills Account Number:

For Utility Assistance

Mid-American Account Number:

For Utility Assistance

Other Account Number:

For Utility Assistance

Gender:

Female Male Other

Citizenship

U.S. Citizen Permanent Resident Alien Not US Citizen/Permanent Resident

Social Security Number:

No Dashes

Date of Birth:

Ethnicity:

Hispanic Non-Hispanic

Race:

Primary Language:

Please select all that apply:

Disabled Veteran Limited English Proficiency

Year of Discharge:

Discharge Type:

Honorable Other Than Honorable Other

Highest Level of Education:

Marital Status:

Total Number of people in household

Number of Adults in Home

Spouse/CoHead Name:

First Name Last Name

Spouse/CoHead Date of Birth:

Spouse/CoHead Age:

Spouse/CoHead Ethnicity:

Hispanic Non-Hispanic

Spouse/CoHead Race:

Ex: Black, Mixed Race, Asian, White, etc.

Spouse/CoHead Residency:

U.S. Citizen Permanent Resident Alien

Spouse/CoHead SSN:

Minor Children In Home:

Full Name

Date of Birth

Gender

School Name

Minor Child 1

Minor Child 2

Minor Child 3

Minor Child 4

Minor Child 5

Minor Child 6

Minor Child 7

Minor Child 8

Minor Child 9

Minor Child 10

Employment Status:

Employer Name:

Additional Employer Names:

Number of Hours/Week:

Hourly Rate:

Monthly Income (in USD):

Annual Income (in USD):

Spouse/CoHead Employer Name:

Spouse/CoHead Monthly Income (in USD):

Spouse/CoHead Annual Income (in USD):

Combined Monthly Income (in USD):

Combined Annual Income (in USD):

Check all that apply:

Food Stamps/EBT SSDI/SSI Child Support ADC Other

Food Stamp/EBT Amount (monthly):

SSDI/SSI Amount (monthly):

Child Support Amount (monthly):

ADC Amount (monthly):

Other Amount (monthly):

Insurance Type:

Do you have or are you at risk for any of the following (select all that apply):

Eviction Foreclosure Utility shut-off Fair Housing Issue

Do you have or are you at risk for any of the following (select all that apply):

Domestic Violence Alcohol Abuse Drug Abuse Other Addiction

Do you have or are you at risk for any of the following (select all that apply):

Physical Disability Mental Illness HIV/AIDS Other

What other services do you think you will benefit from?

Adult Education Services Child Education Services Employment Tools None of the above Other - please list below

Other Services

If selected other please list what services you would like assistance with.

Cause for Hardship (write a brief statement explaining what got you behind, i.e. job loss, COVID-related, illness, etc.):

Sustainability (write a brief statement of your plan to sustain monthly expenses in the future):

By signing below, I/we certify that we have completed this form with honesty and to the best of my knowledge.

Primary Applicant Signature: *

Clear

Today's Date: *

Date

Spouse/CoHead Signature:

Clear

Today's Date:

Date

Client Application--

Demographics

Employment/Income

Additional Needs