St. Vincent De Paul Rent & Utility Request Form

Based on your address, you do not live in the Neyer Outreach Center service area.

Please visit our website and enter your address into our map to find the Conference (group of St. Vincent de Paul volunteers) who serve your area.

You can also call our Call Center at 513-421-0602 to request a referral to your Conference.

Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Format: (000) 000-0000.
Alternate Number
Email
example@example.com
How many adults are in your household (including yourself)?
How many minors (age 17 and younger) are in your household?
Do you have custody of ANY of the minors in your household?
Even if you only have custody of one of the minors counted above, please answer "yes" to this question.
Does your household receive income through Employment or Benefits?
Do you have health insurance?
Who is your provider?
CareSource, Anthem, Humana, etc.

How many times have you applied for financial assistance in the last 30 days?
What kind of financial assistance do you need help with?
Please note that we can only provide assistance to the person who is the head of the lease or mortgage, or whose name is on the utility bill.

Address where you are moving
Landlord Name or Property Name
Landlord/Rental Office Phone Number
This question is not required, but if selected for assistance you will need to bring your landlord's contact information to your appointment. Format: (000) 000-0000.
What will be your monthly rent?
If your rent will be subsidized, only include the portion that YOU are responsible for paying.
What is the deposit amount owed?
Amount you will be able to pay, or raise from other sources?

Do you have a disconnection notice?
Date of Disconnection

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is your utility currently shut off?
What is the total amount owed for gas/electric?
What is the minimum you must pay to avoid disconnection/reconnection for gas and electric?
How much will you be able to pay?

Do you have a disconnection notice?
Date of Disconnection

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What is the total amount owed for water?
What is the minimum amount you must pay to avoid disconnection/reconnection for water?
How much will you be able to pay?
Do you pay rent or mortage?

How much is your monthly mortgage?
How many months are you behind?
What is the full balance of the late mortgage payment?
Name of Bank/Mortgage Lender
Phone Number of Bank/Mortgage Lender
This information is not required, but if you're selected for assistance, you will need to bring the bank/mortgage lender's information to your appointment.Format: (000) 000-0000.

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

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

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.
How was this Request form Completed
St. Vincent de Paul's mission is to share hope and love. Even if we're not able to assist you financially, we would like to pray for you. Please enter any prayer requests below and our staff will offer them up.
Call Center/Welcome Room Staff:

Please ask neighbor, "Would you like me to pray for you today?"
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

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 more than 1 month of rent is due.

Financial assistance is not guaranteed. We will only contact those we are able to assist.

If you do not recieved a phone call within seven business days of submitting this request, this means our team was not able to assist you this week. You may reapply by calling the Call Center (513-421-0602) or completing another online request.

Please click "SUBMIT" below to submit your request.
Date of Last Rent or Utility Service received? If no financial service has been rendered in the past please add None.
Should be Empty:

St. Vincent de Paul - Cincinnati