Request for MAHUBE-OTWA Services
Name
*
First Name
Last Name
Birth date
*
Last 4 digits of your Social Security Number (if available)
Address (To help us determine which office is best to serve you)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county do you live in?
Please Select
Becker
Hubbard
Mahnomen
Otter Tail
Wadena
How do you self identify?
Please Select
Female
Male
Non-Binary
Prefer not to say
What is your race (check all that apply)
American Indian or Alaska Native
Asian
Black (African American)
Native Hawaiian or Other Pacific Islander
White
Other
Unknown
Are you Hispanic / Latino origin?
Yes
No
How do you prefer to be contacted?
No Preference
Email
Phone Call
Text
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Back
Next
What is your approximate annual household income?
Please Select
Less than $19,999 a year
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 or more
How many people live in your household?
Please Select
Just Me
2
3
4
5
6
7
8
9
10+
What type of Medical Insurance do you have?
Please Select
None
Direct Purchase
Employment based
Indian Health Insurance
Medicaid
Medicare
Military
State CHIP
State Insurance for Adults
Do you or someone in your household have a disability
No Disabilities
Breathing
Cognitive
Hearing
Learning
Mental Illness
Orthopedic
Physical
Speech
Visual
Other
Back
Next
MAHUBE-OTWA can help
What types of services are you interested in learning more about?
Home Assistance
Energy related issues (paying energy bills, insulating, furnace or water heater repairs)
Eviction notice guidance and support
Finding affordable housing or a place to rent
Rental deposit
Child Care Assistance
Assistance paying for childcare
Finding affordable and quality child care
Pre-School & Early Learning opportunities for pregnant moms and children birth to five years.
Other Assistance
Child support modification
Health insurance guidance & Medicare counseling
Income tax assistance
Legal issues
Reproductive health, birth control, STI screening, treatment & counseling
SNAP (Supplemental Nutrition Assistance Program)
Submit
Should be Empty: