Client Application

Client Application

Tenant Services, a Division of Family Housing Advisory Services, Inc.
Please complete and submit 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 *

Month Day Year
Request Type: *
Other - Please Specify
Example : Mortgage, Fair Housing
Initial Contact:
Full Name: *

First Name Middle Name Last Name
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
County:
Choose One: *

Rent Own Other
Current Living Situation: *
How long have you been at your address? *
Ex: 5 Months, 3 Years, 10 years
If Yes, Select One:

Section 8 Public Housing Other
Subsidized Housing? : *

Yes No
Number of bedrooms in home:
Emergency Contact:

First Name Last Name
Emergency Contact Phone Number:
Please enter a valid phone number.
Relationship to you:
Ex: Mother, Father, Friend, Aunt. If you do not have an emergency contact please leave blank.
Please select Utility Bill(s) that assistance is needed for:

OPPD MUD Black Hills Mid- American Other
OPPD Account Number:
MUD Account Number:
Black Hills Account Number:
Mid-American:
Other:
How much are you requesting for Rental Assistance?
How much are you requesting for Deposit Assistance?
If you are not already renting, when do you plan to start?
Ex. In the next 3 months, Next Year
Gender: *

Female Male Other
Date of Birth: *

Month Day Year
Date
Ethnicity: *

Hispanic Non- Hispanic
Race: *
Citizenship: *

U.S Citizen Permanent Resident Not U.S. Citizen/Permanent Resident
Social Security Number or ITIN:
Primary Language: *
Please select all that apply: *

Disabled Veteran Limited English Profiency None of the above
Branch of Service:
Ex: Air Force, Army
Year of Discharge:
Discharge Type:

Honorable General Discharge - Under Honorable Conditions OTH (Other Than Honorable) Dishonorable Discharge Entry- level Separation Medical Separtaion
Highest Level of Education: *
Marital Status: *
Total Number of people in the Household? *
Number of Adults in the Home? *
Spouse/ Cohead Name: *

First Name Last Name
Spouse/Cohead Date of Birth: *

Month Day Year
Spouse/Cohead Race: *
Spouse/Cohead Ethnicity: *

Hispanic Non-Hispanic
Spouse/Cohead Citizenship:

U.S. Citizen Permanent Resident Not U.S. Citizen/Permanent Resident
Spouse/Cohead Social Security Number or ITIN:

Employment Status: *
Employer Name:
Additional Employer Names:
Hourly Rate:
Number of Hours/Week:
Spouse/Cohead Employer Name:
Spouse/Cohead Additional Employer Names:
Spouse/Cohead Hourly Rate:
Spouse/Cohead Number of Hours/Week:
Check all that apply:

Food Stamps/EBT/SNAP SSDI (Social Security Disability) SSI (Supplemental Security Income) Child Support ADC Other
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 the 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
Other Services: Please list what services you would like assistance with.
Cause of Hardship (write a brief statement explaining what got you behind, i.e. job loss, Covid-realted, illness, etc.) *
Sustainability (write a brief statement of your plan to sustain monthly expenses the future, i.e. applying for Jobs, returning to work after leave) *
Household Budget

Please fill in your MONTHLY income and outgoing below. If you have no income or not spending money in categories below please enter zero.
Gross Income: Pre-Tax Income *
Net Income : After- Tax Income *
Gross Income Spouse/Cohead:
Net Income Spouse/Cohead:
Social Security:
Unemployment Benefits:
Child Support:
Gratuities/Tips:
Alimony:
Food Stamps/EBT/SNAP:
ADC/TANF:
Pension/Retirement:
Foster Care:
School Grants:
Other:
Total NET Monthly Income:
This will calculate on its own.
Rent:
Renter's Insurance:
Heat & Water:
Electricity:
Trash/Recycling Collection:
Phone/Cell Phone:
Cable/Satellite/Internet:
Streaming Service:
Ex. Netflix, Hulu, HBO
Transportation Type:

Car Public
Car Payment/Lease:
Car Insurance:
Gas/Fuel:
Bus/Taxis/Ride Shares/Public Transport:
Health Insurance Premiums:
Medicine/Prescriptions:
Child Care:
Groceries/Pet Food & Supplies:
Child Support:
Bank Loan(s):
Credit Card(s):
Student Loan(s):
IRS Payment(s):
Medical Bill(s):
Dental Bill(s):
Car Maintenance:
Household Supplies; toiletries, cleaning supplies, etc.
Donations:
Entertainment/Restaurants:
Memberships:
Total Monthly Expenses:
This will auto fill, no need to enter any information.
Money Remaining:
For office use only. This will auto fill, no need to enter any information.

Authorization & Liability Waiver

Family Housing Advisory Services, Inc.
Please submit a copy of the following documents in order for us to determine eligibility.
- ID
- Social Security OR ITIN OR IRS Tax document (may be required for children if applicable)
- Notice (e.g. 3, 7, or 14-day notice) OR a ledger OR a statement from the landlord of the balance owed. You may also upload a court summons if you have one.
- Approval letter from the landlord (for deposit requests)
- Utility bill (for utility requests)
- Proof of hardship to show why you fell behind (letter from employer, paycheck
- stub, bank statements, medical statement)
- Money order for late fees (if applicable)
PLEASE NOTE: Submitting this application does not guarantee approval and processing can take up to 10 business days for some request. Please be advise, additional documents may be requested upon review of your application. Thank you!

Cancel of
I/we Primary Name and Spouse/Cohead whose signature(s) appear(s) below, give permission to Family Housing Advisory Services, Inc. (hereafter "FHAS, Inc."), its employees, and/or attorneys and representatives, to consult with others and obtain from others or provide to others any and all information deemed necessary to assist me with my housing needs including, but not limited to: Information from any State or Federal agency, information regarding my income, all health, medical, and educational information.
I agree to hold FHAS, Inc., its employees, attorneys, representatives and members of its Board of Directors faultless and release them from all liability for their good faith attempt to assist me/us. I also hereby authorize any third person, agency, or organization to provide any such information requested by FHAS, Inc., regarding myself and my minor children, namely:
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
to FHAS, Inc., its employees, attorneys, or representatives and further, hereby fully release any such person from any liability for providing any such information. This authorization is valid for 12 months from the date below unless I have designated a shorter time in the space below or sooner revoke this authorization. A copy, electronic image or emailed version of this release shall be considered an original.

The period of authorization, if less than 12 months, is blanks months from the date below.
Primary Applicant Signature: *

Clear
Spouse/Cohead Signature:

Clear
Today's Date: *

Month Day Year
Should be Empty:

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Client Application

Household Budget

Authorization & Liability Waiver