Client Application

Client Application

Tenant Services, a Division of Family Housing Advisory Services, Inc.
Please complete the entire application and submit all required documentation in order for our team to review your request.

Note: Please be sure to attach all required documents. Incomplete applications will not be reviewed for assistance.
Today's Date of Application*

MonthDayYear
Request Type:*
Is your hardship COVID related? If YES, you must provide proof of COVID related hardship.

YesNo
Have you completed an application for rental assistance with another agency?*

YesNo
If yes, please list name of agency.
Example: MACCH, Together Inc., Heartland, Heart Ministry, NCAP, Etc.
Please Select Workshop

Housing MattersRent Wise
Other - Please Specify
Example : Mortgage, Fair Housing
Referred By:
Why are you interested in taking this class?
Initial Contact:
Full Name:*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
Would you like to receive text messages to attend our upcoming workshops and conference?*

NoYes
Email Address:
example@example.com
Current Address:

Street Address

Street Address Line 2

CityState

Zip Code
County:
Choose One:*

RentOwnOther
Current Living Situation:*
Length of Occupancy?*
How long have you been at your address. Ex: 5 Months, 3 Years, 10 years
If Yes, Select One:

Section 8Public HousingOther
Subsidized Housing? :*

YesNo
Number of bedrooms in home:
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.
Relationship to you:
Ex: Mother, Father, Friend, Aunt. If you do not have an emergency contact please leave blank.
Please select Utility Bill(s) that assistance is needed for:

OPPDMUDBlack HillsMid- AmericanOther
OPPD Account Number:
MUD Account Number:
Black Hills Account Number:
Mid-American:
Other:
How much are you requesting for Rental Assistance?
How much are you requesting for Deposit Assistance?
If you are not already renting, when do you plan to start?
Ex. In the next 3 months, Next Year
How many bedrooms are you looking for?
Rent Range?
What would be your ideal rent range. Example: $600-700 a month
How many bathrooms are you looking for?
Do you have a Section 8 Voucher?

YesNo
Gender:*

FemaleMaleNon- BinaryPrefer not to specify
Date of Birth:*

MonthDayYear
Date
Age range*

18 to 24 Years25 to 44 Years45 to 64 Years65 Years and Above
Race*
Are you of Hispanic or Latino/a origin?*

YesNo
Citizenship:*

US CitizenPermanent ResidentNot U.S. Citizen/Permanent Resident
Social Security Number or ITIN
Primary Language:*
Please select all that apply:*

DisabledVeteranLimited English ProfiencyNone of the above
Branch of Service:
Ex: Air Force, Army
Year of Discharge:
Discharge Type:

HonorableGeneral Discharge - Under Honorable ConditionsOTH (Other Than Honorable)Dishonorable DischargeEntry- level SeparationMedical Separtaion
Highest Level of Education:*
Marital Status:*
Total Number of people in the Household?*
Number of Adults in the home?*
Number of Children in the home?*
If NO children reside in home enter zero.
Co-Applicant:*

First NameLast Name
Co-Applicant:*

MonthDayYear
Co-Applicant Ethnicity:*

HispanicNon-Hispanic
Co-Applicant Gender:*

FemaleMaleNon- BinaryPrefer not to specify
Co-Applicant Citizenship:

U.S. CitizenPermanent ResidentNot U.S. Citizen/Permanent Resident
Co-Applicant Social Security Number or ITIN:

Minor Children in Home:

	Full Name	Date of Birth	Gender	School Name	Race/Ethnicity
Minor Child 1
Minor Child 2
Minor Child 3
Minor Child 4
Minor Child 5
Minor Child 6
Minor Child 7
Minor Child 8
Minor Child 9
Minor Child 10

Employment Status:*
Employer Name:
Additional Employer Names:
Hourly Rate:
Number of Hours/Week:
Co-Applicant Employer Name:
Co-Applicant Race
Co-Applicant Employment Status:
Co-Applicant Additional Employer Names:
Co-Applicant Hourly Rate:
Co-Applicant Number of Hours/Week:
Check all that apply:

Food Stamps/EBT/SNAPSSDI (Social Security Disability)SSI (Supplemental Security Income)Child SupportADCOther
Other
Insurance Type:*
Do you have or are you at risk for any of the following (select all that apply):*

EvictionForeclosureUtility shut-off/DisconnectionFair Housing IssueNone of the above
Do you have or are you at risk for any of the following (select all that apply):

Domestic ViolenceAlcohol AbuseDrug AbuseOther AddictionNone of the above
Do you have any of the following? (select all the apply):

Physical DisabilityMental IllnessHIV/AIDSOtherNone of the above
What other services do you think you will benefit from?*

Adult Continuing Education ServicesChild Education ServicesEmployment ToolsNone of the aboveOther (e.g. Behavioral/ Mental Health Referral, Grief Support, Community Resource Information...)
Other Services: Please list what services you would like assistance with.
May we include a soft pull of your credit report with your budget?

YesNo
Cause of Hardship (write a brief statement explaining what got you behind, i.e. job loss, illness, COVID related, etc.)*
Is your Financial Hardship due to COVID-19

YesNo
Sustainability (write a brief statement of your plan to sustain monthly expenses the future, i.e. applying for Jobs, returning to work after leave)*
Short Term Goal (0-6 months) *
Long Term Goal (6+ months)*
Household Budget

Please fill in your MONTHLY income and outgoing below. If you have no income or not spending money in categories below please enter ZERO or leave blank.
Gross Income: Pre-Tax Income*
Net Income : After- Tax Income:*

Under $15,000$15,000 to $24,999$25,000 to $34,999$35,000 to $49,999$50,000 to $74,999$75,000 and Above
Gross Income: Co Applicant*

Yes- Please answer next questionNo- Skip next question
Net Income Co-Applicant:

Under $15,000$15,000 to $24,999$25,000 to $34,999$35,000 to $49,999$50,000 to $74,999$75,000 and Above
Social Security:
SSDI or SSI Monthly Income Total
Unemployment Benefits:
Child Support:
Gratuities/Tips:
Alimony:
Food Stamps/EBT/SNAP:
ADC/TANF:
Pension/Retirement:
Foster Care:
School Grants:
Other:
Total NET Monthly Income:
This will calculate on its own.
Rent:
Renter's Insurance:
Heat & Water:
Electricity:
Trash/Recycling Collection:
Phone/Cell Phone:
Cable/Satellite/Internet:
Streaming Service:
Ex. Netflix, Hulu, HBO
Transportation Type:

CarPublic
Car Payment/Lease:
Car Insurance:
Gas/Fuel:
Bus/Taxis/Ride Shares/Public Transport:
Health Insurance Premiums:
Medicine/Prescriptions:
Groceries/Pet Food & Supplies:
Household Supplies; toiletries, grooming
Child Care:
Child Support:
Bank Loan(s):
Credit Card(s):
Student Loan(s):
IRS Payment(s):
Medical Bill(s):
Dental Bill(s):
Car Maintenance:
Donations:
Entertainment/Restaurants:
Memberships:
Total Monthly Expenses:
This will auto fill, no need to enter any information.
Money Remaining:
For office use only. This will auto fill, no need to enter any information.

Authorization & Liability Waiver

Family Housing Advisory Services, Inc.
Please submit a copy of the following documents in order for us to determine eligibility.
- ID
- Social Security OR ITIN OR IRS Tax document
- Lease (for rental request only)
- Notice (e.g. 3, 7, or 14-day notice) OR a ledger OR a statement from the landlord of the balance owed. You may also upload a court summons if you have one.
- Approval letter from the landlord (for deposit requests only)
- Utility bill (for utility requests only, bill must be in the name of the applicant)
- Proof of hardship to show why you fell behind (letter from employer, paycheck stub, bank statements, medical statement) *If your hardship is COVID related, you must provide PROOF of COVID
- Proof of Income from the last 60 days (Paystubs, Unemployment comp, Child Support, *Bank Statements, Social Security, SSDI, Child Support)
  - Note: If you have any bank accounts, you must provide complete bank statements, including the last page of the statement, even if the last page is blank.
For all Housing Search Request and Education Registration DO NOT upload any documents. Both request do not require documentation to attend our class or to recieve a housing search list.
PLEASE NOTE: Submitting this application does not guarantee approval and processing can take up to 10 business days for some request. Please be advise, additional documents may be requested upon review of your application. Thank you!

Cancelof
I/we Primary Name and Spouse/Cohead whose signature(s) appear(s) below, give permission to Family Housing Advisory Services, Inc. (hereafter "FHAS, Inc."), its employees, and/or attorneys and representatives, to consult with others and obtain from others or provide to others any and all information deemed necessary to assist me with my housing needs including, but not limited to: Information from any State or Federal agency, information regarding my income, all health, medical, and educational information.
I agree to hold FHAS, Inc., its employees, attorneys, representatives and members of its Board of Directors faultless and release them from all liability for their good faith attempt to assist me/us. I also hereby authorize any third person, agency, or organization to provide any such information requested by FHAS, Inc., regarding myself and my minor children, namely:
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
Minor First Name   Last Name   Date of Birth
to FHAS, Inc., its employees, attorneys, or representatives and further, hereby fully release any such person from any liability for providing any such information. This authorization is valid for 12 months from the date below unless I have designated a shorter time in the space below or sooner revoke this authorization. A copy, electronic image or emailed version of this release shall be considered an original.

The period of authorization, if less than 12 months, is blanks months from the date below.
Today's Date:*

MonthDayYear
Primary Applicant Signature
Co-Applicant Signature
Employee Signature
Thank you for reaching out to us in your time of need. We can not guarantee funding will be available, due to funding limitations. Please allow 7-10 business days for a response.
Should be Empty:

Client Application

Household Budget

Authorization & Liability Waiver