Client Application

Date of Application: *

Today's Date

Request Type: *

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