Fillable Assistance Application Form

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Assistance Application Form

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The Assistance Application Form form is 2 pages long and contains:

  • 1 signature
  • 12 check-boxes
  • 29 other fields

Country of origin: OTHERS
File type: PDF

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Assistance Application Form
1. HEAD OF HOUSEHOLD:
Name: ___________________________________________________________________________
No Are you a Veteran? Yes ____ ____
Tribal Affiliation __________________________________
Enrollment number _______________________________
2. CONTACT INFORMATION:
Street Address: ________________________________________________________________
City/District: __________________________________________________________________
Email: Phone: ____________________________ ____________________________________
3. HOUSEHOLD INFORMATION:
How many people live in the household? _____________
_residents over 50 years oldNumber of residents under 18 years old: ___________ ________
Number of bedrooms in house: ____________
4. HOUSEHOLD INCOME:
Include type of income (wage, commission, pension/retirement, unemployment, SSI, TANF, EBT, Other) and
total yearly earnings of each individual:
__
__
_______________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Total household annual income: $ ____________________
5. RENTAL INFORMATION: (Eligible dates: March 13, 2020 – December 31, 2021
(attach proof of rent) Monthly rental amount: _____________________
__OSLH Unit # No Do you owe back rent? Yes __ __ Total rent owed: __________ ___________________
___ ____ NoAre you receiving financial assistance from any other source? Yes
If yes, what source? ______________________________________________________________________
Landlords name: _________________________________________________________________________
Emergency Rental Assistance Program
P.O. Box 603 Pine Ridge, SD 57770
4 Suanne Center Drive
Phone: 605-867-5161 Fax: 605-867-1095
Landlords Street Address: _________________________________________________________________
Zip code: State Landlords City/District: ___ _________________________ __________________ __________
/ DUNS #Social Security #Landlords Phone: _______________ _______________ ____________________
No Are Utilities included in rent? Yes ___ ____
6. UTILITY INFORMATION:
(Utilities include: electricity/energy, propane, natural gas, fuel oil, wood, water, trash removal, other) Please
attach bill?
Total owed:No Do you owe utility payments? Yes ___ ___ __________________________
Utility company owed: ____________________________________________________________________
____ ____ No if yes, how much/what utilities?Do you receive utility assistance? Yes __________________
______________________________________________________________________________________
7. CERTIFICATION:
• I/We certify that all information furnished in this application for Emergency Rental Assistance is true
and complete to the best of my/our knowledge.
• I/We certify that our household is not receiving any other government-funded rental assistance.
• I/We certify that our household does not have access to other resources sufficient to cover the rent
and/or utilities.
• I/We understand that any false statement, made knowingly and willfully, will be sufficient cause for
rejection of my/our application.
• I/We understand that landlord participation in this program is required.
• I/We understand than ANY false information on this application or statements given are punishable by
law and will lead to cancellation of this application and rental assistance.
Applicants signature: ______________________________ Date: ________________________
Submit the completed application via email to Carrie Rowland at
carrie@oslh.org or drop it off at the district OSLH maintenance office.
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Assistance Application Form

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Completed 8 March 2021

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