Outside the Walls Assistance Application

Outside the Walls Assistance Application
Section 1 - Contact Information
Full Legal Name*

First NameMiddle NameLast Name
Prior / Maiden Name
Date of Birth*

MonthDayYear
Date
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email*
example@example.com
Section 2 - Housing/Auto Information
Current Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at the address provided above?*
Have you lived in Washington County for more than one year?*

YesNo
Please select one of the following*

I'm renting/leasing the home at the address provided aboveI'm buying the home at the address provided aboveI am a homeowner (no mortgage)
Rental Information
Landlord's Name

First NameLast Name
Landlord's Phone Number
Please enter a valid phone number.
Name(s) on the Lease/Rental Agreement
Is anyone in the household related to the landlord?

YesNo
What utilities are included in your rent?

WaterGasElectric
Are you current on your rent payment?

YesNo
Buying a Home Information
Mortgage Holder Name
Mortgage Holder Phone Number
Please enter a valid phone number.
Name(s) on the Mortgage
Are you current on your mortgage payment?

YesNo
Prior Home Address
Prior Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Landlord Name*

First NameLast Name
Prior Landlord Phone*
Please enter a valid phone number.
About your Household Vehicle(s)
Vehicle Number 1 - Provide Year /Make /Model*
Vehicle Number 2 - Provide Year /Make /Model
(If Applicable)
About Your Household
Is the anyone disabled living in your home?*

YesNo
Please indicate the special needs:
Is anyone in the home a veteran?*

YesNo
Do you or any family member belong to any of these non-profit organizations?*

NoneChurchVeteran StatusSalvation ArmyUnited WayOther
Please elaborate on your answer of "Other"
How many people are in your household (including yourself)?*
Household Member #2
Household Member #3
Household Member #4
Household Member #5
Household Member #6
Household Member #7
Household Member #8
Household Member #9
Household Member #10
Section 3 - Financial Information
PLEASE NOTE: Financial information provided must be provided and acknowledged with a signature by all adult household members.
Is the primary applicant currently employed?*

YesNo
What is the name of your Employer?
What was your last date of employment?
What were the circumstances concerning the end of your employment?
Household Income

Enter any and all Monthly Income amounts below: *

	Monthly Income ($)
Wages (Self)
Wages (Spouse)
Social Security
Disability
Workers' Compensation
Veterans' Benefits
Food Stamps
Child Support
Unemployment
Pension
TANF
Any other Income

Household Expenses

Enter any and all Monthly Expense amounts below:*

	Monthly Expenses ($)
Rent or Mortgage
Renters/Homeowners Insurance
Natural / Propane Gas
Electric
Water
Telephone / Cellular
Internet / Cable / Satellite
Food (Including food/paper products & diapers)
Cigarettes
Auto Loan Payment
Auto Insurance
Gasoline
Medical Bills
Health Insurance
Medicine / Pharmaceuticals
Child Care
Child Support Payment
Credit Cards
Rent to Own
Additional Loans
Any Other Expenses

Would you like to receive budgetary recommendations based on your financials?*

YesNo
Section 4 - Assistance Information
PLEASE NOTE: Outside The Walls Inc. limits applicants and members of a household to assistance 1x per year (from date of application)
What is your main need today?*

Ramp*Utility Assistance**Rent Assistance***Home RepairCar RepairGasOther
Please clarify your answer of "Other"
* If your primary need is a ramp, please have a medical doctor or medical facility email us the verification of medical necessity to OTW. Email to info@outsidethewallswashco.org

** Utility assistance only provided if in DISCONNECT status (must provide proof)

**OTW requires those seeking utility assistance to first apply with their township trustee, salvation army and EAP(Hoosier Uplands). We also require a copy of the notice of action from each county agency which states the date of assistance and amount. If denied, denial notice required. Please email notice and a copy of most recent bill to info@outsidethewallswashco.org.

***Rent assistance only provided if in EVICTION status (must provide proof)
A Note Concerning Utilities Assistance

For assistance with a utility bill please contact the following before submitting an application to Outside the Walls.

Southern Hills Church 812-883-1637

Washington County Township Trustees
Other Assistance Received

Outside The Walls requires all applicants to apply with the Salvation Army and their Township Trustee (list provided below) prior to submitting an application with us. A written approval/denial letter from both entities will be required as part of this application process.
Have you asked for assistance from your Township Trustee?*

YesNo
View a list of the Washington County Township Trustees - Updated Sept 2023
Washington County Township*
Your Washington County Township Trustees’ Name
Your Washington County Trustees’ Phone Number
Please enter a valid phone number.
Have you asked for assistance from the Salvation Army?

YesNo
Upload a copy of your most recent utility bill

Cancelof
Please describe your need today*
Would you or any member or your household be willing to volunteer help and/or service to other projects and/or organizations when able?*

YesNo
Do you or anyone in your household currently receive or have recently applied for assistance from any of the following organizations? (Check all that apply)*

Subsidized HousingUtility AllotmentWICSalvation ArmyMedicaidFood Stamps (SNAP)Church AssistanceFamilyFriendTrusteeVAOther
Please provide more information on your answer of "Other"
Section 5 - Acknowledgement
How did you hear about Outside The Walls?
- Manpower for OUTSIDE THE WALLS, INC. is made up of community volunteers. These volunteers donate their time and talents to help those in need. However since our projects are dependent upon volunteers we may have to reschedule or complete a project at a later date. When OUTSIDE THE WALLS, INC. makes a commitment to a project it will be completed, however it may take more time than anticipated and may not get completed in a day, so an additional day of completion may be rescheduled.
- Also, OUTSIDE THE WALLS, INC. may use your name and/or information as a tool to solicit funds for your project and/or for other projects.
- I certify and affirm that the information I have given on this application is true and correct to the best of my knowledge and belief in every respect as to all members listed on this application. I have not omitted any means of support.
- I understand that misrepresentation or omission can be cause for denial.
- I give permission for OUTSIDE THE WALLS, INC. to verify any application information with the appropriate person or agencies and to share information that would be helpful in understanding my needs and/or situation, and I give consent to such persons or agencies to release information to
  OUTSIDE THE WALLS, INC.
- I agree to hold harmless OUTSIDE THE WALLS, INC. it’s staff, board members, volunteers, and donors against any ill effects suffered in the use of any items received through this Program.
- All material used for a project becomes property of the homeowner. If the material is no longer needed, please contact OTW to donate back.
Applicant’s Signature*

Clear
Co - Applicant Signature (if applicable)

Clear
Should be Empty:

Outside the Walls Assistance Application

Section 1 - Contact Information

Section 2 - Housing/Auto Information

Rental Information

Buying a Home Information

Prior Home Address

About your Household Vehicle(s)

About Your Household

Section 3 - Financial Information

Household Income

Household Expenses

Section 4 - Assistance Information

Other Assistance Received

Section 5 - Acknowledgement