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