Language
English (US)
Date
*
-
Month
-
Day
Year
Date
E-mail
*
Full Name
*
First Name
Last Name
Address
*
Street Address
Apt
City
State
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Birth Date
*
mm/dd/yyyy
Age
*
Gender
*
Male
Female
Other/Non-Conforming
Born in USA?
*
Yes
No
Other
If Other, what country?
Marital Status
*
Single
Married
Widow/Widower
Ethnicity
*
Hispanic
Non-Hispanic
Race
*
White
Black/African-American
American Indian/Alaskan
Asian
Hispanic
Native Hawaiian/Pacific Islander
Hispanic Black
Multiple race
Other
Household Size
*
1
2
3
4
5
6
7
8
9
10+
How Many Adults?
*
1
2
3
4
5
6
7
8
9
10+
How many under the age of 18?
*
0
1
2
3
4
5
6
7
8
9
10+
Housing Status
*
Own
Rent
Rent-to-Own
Live with others
Other
Housing Expense $
*
Household lives in a rural area
*
Yes
No
Choose not to respond
Occupation
*
Employed
Self-employed
Unemployed
Social Security
Other
Household Annual Gross Income $
*
Education
*
College
Some College
Graduate School
High School/GED
Junior College
Post Graduate
Junior High School
Vocational
Unknown
Are you a U.S. Citizen?
*
Yes
No
English Proficient?
*
Yes
No
Active Military?
*
Yes
No
How did you hear about us?
*
Word of Mouth
Oasis staff
Internet/Social Media
Radio/Ad/Flyer
School Referral
Realtor
Bank/Lender
Church
If referred by a school, please provide name of school and case worker.
If connected to a church, please provide the name of the church.
Which assistance are you seeking?
*
Rental Assistance (Past due / Future Rent)
Move-In Security Deposit Assistance
Locating Rental Housing
Mortgage Assistance
Foreclosure Prevention Counseling
Homebuyer Education
Pre-Purchase Counseling
Down Payment & Closing Cost Assistance
New Construction Home
Financial Management & Budget Counseling
Youth & Young Adult Financial Literacy
Signature
*
Clear
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Back
Next
Signature
*
Clear
Signature
*
Clear
Choose one option.
*
Box 1 - Limitdisclosure of personal information about me to unaffiliated third parties otherthan nonprofit organizations involved in community development.
Box 2 - Limit disclosure of personal information about me to nonprofitorganizations involved in the community development that are used only for program review, auditing, research, and oversight purposes.
Signature
*
Clear
SUBMIT
Should be Empty: