Emergency Rental, Rapid Re-Housing and Utilities Assistance

Date*

Date

Name*

First NameLast Name

Date of Birth

Date

Are you homeless?*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Are you on a waiting list for other housing options?*

NoSection 8/OHFAOCHAOther

If you selected other, please provide.

Are you 18 years old or over?*

YesNo

Do you have in your physical possession any of the following forms of ID?*

Social Security CardBirth CertificateState ID or Driver's LicenseNone

Is your household income*

Less than $22,000Between $22,000 and $44,000?Over $44,000?

Do you have a written past due notice on your rent?*

YesNo

Do you have a Notice to Quit where you are currently living?*

YesNo

Do you have an eviction notice with a court date?*

YesNo

If you have an eviction notice with a court date, when is your court hearing?

Date

Do you have a written past due notice on your utilities?*

YesNo

Have you received any other assistance from a government fund?*

YesNo

Did you lose your job or receive less pay because of COVID-19?*

YesNo

Have you been unemployed for the last 90 days or more?*

YesNo

Is your situation due to being a victim of domestic violence?*

YesNo

Do you have a pet?*

YesNo

What are your immediate needs?*

If you chose shelter, do you have somewhere safe to stay tonight?

YesNo

If you have a safe place to stay tonight, where? If you do not have a safe place to stay tonight, please call us directly for a list of community shelters at (405) 235-7537.

Transitional Living Program (TINY HOMES)

Tenant Expectations

I will be respectful of staff, self, peers and community residents.
I will remain drug and alcohol free at all times while participating in the program, services will be provided for issues with drugs or alcohol.
I will participate in a life skills group or other services when appropriate.
Participate in job skills training until I secure employment.
I agree to participate in move-in, weekly and pre-move out room inspections with my assigned or other Pivot staff
I will focus on making progress on my goals to become self-sufficient.
I will meet weekly with my assigned Pivot staff member.
I will pay rent per the identified fee schedule.
I will have contact (by text, phone, email, or face to face) with Pivot staff according to the sliding scale
I will go to wellness coaching sessions twice a month.
Visitors allowed only upon prior approval and in line with the visitor policy.
Planned overnight absences from property must be reported to Pivot staff.
Residence is forfeited after 7 days without contact; property will be held for 30 days after which participant forfeits rights to the property.

Are you interested in the Transitional Living Program (Tiny Homes)?*

Yes, I have read the Tenant Expectations and am interested in the Transitional Living Program.No

Are you married?*

YesNo

Do you own a pet?*

YesNo

Cell Phone Number

Please enter a valid phone number.

Home Phone Number

Please enter a valid phone number.

Other Phone Number

Please enter a valid phone number.

Do we have permission to leave a message/text on the numbers provided?*

YesNo

Date*

Date

Signature*

Clear