Pathways Application Form

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Pathways Application Form

This is an application to participate in Pathways, a program which connects households to an OUR Center Resource Specialist and/or to be considered for rental assistance.
***If you need support completing the application, we offer assistance during Resource Now***

Date*

MonthDayYear
Date
I am:*

Applying for myselfAn agency applying on behalf of someone I'm working with

Your name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Agency*
What is your role?*
Who are you referring?*

First NameLast Name
What is their date of birth?*

MonthDayYear
Date
If accepted, will you continue working with the family?*

YesNo
Describe current situation*
What support are you requesting from the OUR Center?*

Rental AssistanceUtility AssistanceFood AssistanceOther
Are you exploring other options and what is the plan for the family's stability?*
Anything else you'd like us to know?*

I have lived in the St Vrain Valley School District for at least 60 days.*

YesNo

Does your rent portion go up or down if your income changes? (ex: Section 8 voucher or project-based housing)*

YesNo

Where is your voucher from?*

Boulder Housing PartnersBoulder County Housing AuthorityLongmont Housing AuthorityProject Based VoucherMental Health PartnersI'm not sure
What is your current rent portion?*
How much do you owe?*
Do you have income?*

YesNo
Please explain why you fell behind on rent? *

Within the last 30 days, have you had any source of income? (work, TANF, SSDI/SSI, child support, unemployment, etc.)*

YesNo

Is the total amount you are requesting from the OUR Center more than $3,000?*

YesNo

In the past 12 months have you received rental assistance from the OUR Center?*

YesNo

Please select the option that applies to you*

Rent is not due yetPast due on rentReceived a demand for paymentCourt date has been scheduledAlready attended eviction courtN/A; requesting deposit

My current monthly rent is:*
How much do you currently owe?*
Please add income for ALL household members below.
Please select all that apply and list the total amount below.*

WorkUnemploymentSSDI/SSIRetirement/PensionTANFChild SupportOther
What is the total amount of ALL household income?*

What other support programs or agencies are you working with?*
Please share a little bit about what's been going on and how it has affected your financial situation.*
Is there anything else you'd like to share?*

Please read the following Authorization to Release Information and add your e-signature below.
I may revoke this authorization at any time, except to the extent that a Partner Agency has acted in reliance upon it, by sending written notification to any Partner Agency. I may acquire a copy of this release at my request. Expiration of Authorization: Unless terminated earlier by me, this authorization will expire one (1) year from the date signed.

Puedo revocar esta autorización en cualquier momento, excepto en la medida en que una agencia asociada haya actuado basándose en ella, enviando una notificación por escrito a cualquier agencia asociada. Puedo obtener una copia de esta autorización si lo solicito. Caducidad de la autorización: A menos que la rescinda antes, esta autorización caducará un (1) año después de la fecha de su firma.
Signature*

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