New Service Application Form
Rebuilding Together Rogue Valley
Lead Status
Who is filling out this form?
*
Client
Relative, Friend or Caregiver
Who is the primary contact?
Client
Relative, Friend or Caregiver
Primary Contact
First Name
Last Name
Relationship to Client
Relative
Friend
Caregiver
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Client Name
*
First Name
Last Name
Client Gender
Please Select
Man/male/masculine
Woman/female/feminine
Transgender
Non-binary
Other / Non-Conforming
Client Race
Please Select
White
African American
American Indian
Hispanic / Latino
Native Hawaiian / Pacific Islander
Asian
Other
Client Email Address
example@example.com
Caregiver (If Applicable)
First Name
Last Name
Client Phone Number
Please enter a valid phone number.
Client DOB
*
-
Month
-
Day
Year
Date
Current Insurance
Please Select
None
Unknown
Medicare
Medicaid
AllCare
OHP
Care Oregon
Member ID (If Known)
Street Address
*
Apartment, suite, etc
City
*
State/Province
ZIP / Postal Code
*
Move-in date
Home Ownership
Own
How many people live in your household (including yourself)?
*
Proof of Home Ownership
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Lease Agreement
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Landlord Approval Letter
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have owners permission if applicable?
*
Yes
No
Are there children under 6 in the home?
*
Yes
No
Do you live in a mobile home?
*
Yes
No
If yes, Do you rent or own your own slab?
*
Rent
Own
If Yes, is the mobile home on wheels?
Yes
No
Services Needed
*
DME (Bars, Risers)
Ramp
DME & Ramp
Large Home Safety Job
Describe repairs needed?
*
Anything else we should know?
HUD Specific Questions
This helps us determine what grants you my be eligible for.
What is your TOTAL GROSS ANNUAL HOUSEHOLD INCOME? (Include all sources for ALL household members - before taxes)
*
Under $17,850
$17,851 - $25,450
$25,451 - $33,950
$33,951 - $42,400
$42,401 - $47,500
$47,501 - $54,300
$54,301 - $67,850
$67,851 - $73,900
$73,901 - $80,000
Over $80,000
INCOME SOURCES
Check all sources of income for your household.
Employment Income:
Wages/Salary (full-time)
Wages/Salary (part-time)
Self-employment income
Tips/Commissions/Bonuses
Government Benefits:
Social Security (retirement)
Social Security Disability (SSDI)
Supplemental Security Income (SSI)
Veterans Benefits (VA)
Unemployment Benefits
Workers' Compensation
TANF/Public Assistance
Retirement/Investments:
Pension payments
401(k)/IRA withdrawals
Investment income (dividends, interest)
Rental income from property
Other:
Alimony/Child support received
Regular contributions from family/friends
Any other regular income
No income / $0 income
Current Benefits Programs
Are you currently receiving any of the following benefits?
Check all that apply
Medicaid / Oregon Health Plan (OHP)
Medicare (with low-income subsidy)
SNAP (Food Stamps)
Section 8 Housing Voucher
Public Housing resident
SSI (Supplemental Security Income)
TANF (Temporary Assistance for Needy Families)
LIHEAP (Low Income Home Energy Assistance)
Oregon SHIBA / Senior Health Insurance Benefits
Veterans Pension (means-tested)
Free/Reduced School Lunch Program (household member)
None of the above
Income Verification
To verify eligibility, we may request documentation such as:- Recent tax return (1040)- Social Security benefit letter- Pay stubs (most recent 30 days)- Bank statements- Benefit award letters
Are you willing and able to provide income documentation if requested?
Yes
Yes, but I may need assistance gathering documents
I am not sure what I have available
I certify that my total annual household income is at or below 80% of the Area Median Income for my county, making me eligible for low-income services.
I certify this statement is true and accurate to the best of my knowledge.
Signature
Submit Application
Submit Application
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