Society of St. Vincent De Paul Request Form

How many times have you applied for financial assistance in the last month? *
What kind of financial assistance do you need help with?*

Rent (Current Month or Past Months)Rent and/or DepositUtilities (Gas and Electric)Utilities (Water)Utilities (Both Gas and Electric and Water)Mortgage
How did you hear about St. Vincent de Paul?*

How many months of rent do you owe the landlord/housing provider?

0 months (Next month's rent)1 month2+ months

Name*

First NameLast Name
Current Address (If you are moving Do Not add New Address in this section, if you are experiencing Homelessness please add Homeless)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone number*
Format: (000) 000-0000.
Alternate Number
Email
example@example.com
How many adults are in the household?*
List ages of all adults*
Do you have custody of children in your home?*
List ages of children in home (ex: 2yrs,14yrs 2mos)
Does your household receive income through Employment, Benefit or Support?*

YesNo
Do you have health insurance?*

YesNo
Who is your carrier? *

If unemployed: Have you or anyone in your household been unemployed for longer than 90 days?*

Yes, I've been unemployed for longer than 90 daysNo, I have worked within the last 90 days

Have you been directly or indirectly impacted by COVID19 since 2020?*

YesNo
Please confirm the service that you need?*

Back Rent (Current month of Past Month)Rent and/or DepositUtilities (Gas and Electric)Utilities (Water)Utilities (Gas an Electric and Water)Mortgage

Have you received a notice to leave the premises (3, 10 day notice)?*

YesNo
Have you received a court summons?

YesNo
When is the court hearing?

MonthDayYear
Date
Do you live in subsidized housing?

YesNo
Housing Provider/Landord Name*
Housing Provider/ Landlord phone #
Format: (000) 000-0000.
What is the monthly rent/mortgage amount YOU are responsible to pay?*
How many months are you behind on rent?*
What months do you need assistance with? (Please spell out the month(s) Ex: January, February)*
What is the total amount owed to your landlord?*
Amount you will be able to pay, or raise from other sources?
How long have you lived at your current residence (Please indicate months or years)?*

New Address (if Deposit)*
We are unable to assist with both rent and deposit. Do you need the Rent along with the Deposit?*

1st Month Rent OnlyDeposit OnlyRent and Deposit
Landlord Name or Property Name*
Landlord/Rental Office Phone Number*
Format: (000) 000-0000.
What is the monthly rent YOU will be responsible to pay?*
What is the deposit amount owed?*
Amount you will be able to pay, or raise from other sources?*

Your name must be on the utility account to be considered for assistance, is your name on the utility bill?

YesNo

Do you have a disconnection notice?*

YesNo
Date of Disconnection

MonthDayYear
Date
Is your utility currently shut off?*
What is the total amount owed for gas and electric?*
What is the minimum you must pay to avoid disconnection/reconnection for gas and electric?*
What is the total amount owed for water?
Minimum amount you must pay to avoid disconnection/reconnection for water
How much of the utility bill(s) will you be able to pay?
Do you pay rent or mortage?*
How much is your monthly rent/mortgage?*
Have to used the Winter Rule this season?

YesNo
Are you currently on PiPP?*

YesNoNot Applicable

We apologize but if you have not yet been approved by the Housing Provider to move into the residence, then we cannot consider your request a for financial assistance.

Once the Housing Provider has given approval for you to move in, you can then submit a request for financial assistance from our organization.
Please Confirm*

I understand that I must be approved by the Housing Provider/Landlord before my request for assistance is considered.

We apologize but if the RTA inspection has not been completed, we will not consider your request for financial assistance for deposit/rent help.

Once your residence has passed the RTA inspection, you can submit a request for financial assistance.
Please Confirm*

I understand that I need the RTA to be approved before submitting a request

Is any household member waiting on benefits in the near future such as a TAX REFUND or other benefits?*

YesNo
If yes, which benefit are you awaiting?
What makes you unable to pay your bills at the current time? (***Details are very important so that the committee can make an informed decision.***)*
How will you be able to pay your bills in the future? Please provide a plan regarding how you will pay next month's bill.*
We have a re-entry program to help those who have had to spend time in prison/jail. Have you or a family member been impacted by prison/jail?*
How was this Request form Completed*
Do you have any prayer requests?
Name of person who completed Request Form.*

Please be aware that we are unable to assist with the payment of any utility bill that is under the name of a person who is not currently residing in the houshold, this includes relatives and landlords.
. Please Confirm*

I understand that assistance will not be offered for a utility bill that is under someone else's name other than my own.

Due to limited funding, if you owe your housing provider more than 1 month's worth of rent then our team will not be able to assist. Our team will not consider requests where 1 month of rent is due.*

I understand that assistance can not be provided for rent balances that exceed 1 months.

The requests for financial assistance are not guaranteed. If our team is able to help with financial assistance, they will only contact those whom the are able to assist.

If you do not recieved a phone call within 7 business days of submitting this request, this means that our team was not able to assist, however you have the option to reapply by going to our website at www.svdpcincinnati.org, if you have not been contacted within that time.

IF YOU ARE APPLYING ONLINE OR IN THE EDUCATION CENTER PLEASE SKIP NEXT QUESTION AND CLICK SUBMIT.
Date of Last Rent or Utility Service recieved? If no financial service has been rendered in the past please add None.
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