OHA Housing Grant Application
Client Name:
*
First Name
Last Name
Client DOB:
*
-
Month
-
Day
Year
Date
What assistance is the client needing?
*
If client is in need of rental assistance, is there an ROI for landlord?
*
Yes
No
Unknown
Does client meet one of the following criteria listed below (check all that apply)?
*
Transitioning from the residential level of care to community.
Transitioning from corrections to community.
Transitioning to a recovery oriented housing program such as Oxford ect.
Without this level of support, the individual is at a higher risk of re-entering a higher level of care or hospital setting.
Homeless or at risk of becoming homeless.
Support towards stability and safety.
Has client reached out to other organizations for similar assistance?
*
Yes
No
Unknown
What is the client's employment/income status?
*
Employed
Not Employed
Unknown
Name and contact information of person referring the client
*
First Name
Last Name
What assistance is the client requesting (check all that apply)?
*
Month to Month Rent
Back Owed Rent
Security Deposit
Application Fees
Late Fees
Utility Assistance
Please give a brief summary as to why the client is in need of this assistance.
Submit
Should be Empty: