You must live in one of the following zip codes to request financial assistance:

75001, 75023, 75115, 75116, 75204, 75205, 75209, 75219, 75220, 75225, 75229
75230, 75231, 75234, 75235, 75240, 75243, 75244, 75247, 75248, 75251
75252, 75254, 75287.

If you do not live in NDSM's service area in one of the zip codes listed above, please call 211 for information on an organization that services your zip code.

You must have sufficient current verifiable income.
You must have a valid email.

Do not submit multiple applications or your applications will not be responded to.

Rent/Utility Applicant Information - Read question carefully. If you fail to fill out any part of this application truthfully, it may be closed without review. DO NOT APPLY MULTIPLE TIMES - YOUR FILE WILL BE CLOSED WITHOUT A RESPONSE.

Name(Required)

Street Address(Required)

Apt #

City(Required)

Zip Code - If your zip code is not listed we do not service your area. Call 211 for information on organization in your area.(Required)

Telephone Number where you can be called.(this field autoformats)(Required)

Type of phone: (this field autoformats)(Required)

Hidden

Social Security #: (this field autoformats)

Photo ID# for applicant only(Required)

Hidden

today Date

Sex (M/F):(Required)

Date of Birth - type the /(Required)

Age

Auto Calculates

Month(s)

Ethnicity:(Required)

Marital Status:(Required)

Email Address:(Required)

Enter Email Address Again:(Required)

Household Information

Total # of people living in household:(Required)

Please enter a number greater than or equal to 1.

Where do you live:(Required)

Do you currently receive assistance through any subsidized program or DHA/Sec 8:(Required)

Apt/Condo/Motel name:(Required)

Apt Number

Landlord Name:(Required)

Phone: (this field autoformats)(Required)

One month's rent is? *$(Required)

Move-in Date - type the /(Required)

(date you moved on to property -this field autoformats)

Time lived at Residence:

Auto Calculates

Month(s)

How many are on Medicaid?(Required)

How many are on SNAP (food stamps, use numbers)(Required)

Monthly Amount from SNAP $

List Information regarding ALL OTHER ADULTS Age 18 or over living in your household: failure to list Adults or children may have your application declined. Date of Birth and SS# will autoformat.

DO NOT LIST YOURSELF BELOW - ANYONE ELSE LIVING AT RESIDENCE MUST BE LISTED

Adult 1 First and Last Name

Adult 1 Sex M/F

Adult 1 Date of Birth

Adult 1 - Relationship to you

Adult 1 Photo ID #

Adult 1 Age

Auto Calculates

Month(s)

Adult 2 First and Last Name

Adult 2 Sex M/F

Adult 2 Date of Birth

Adult 2 - Relationship to you

Adult 2 Photo ID #

Adult 2 Age

Auto Calculates

Month(s)

Adult 3 First and Last Name

Adult 3 Sex M/F

Adult 3 Date of Birth

Adult 3 - Relationship to you

Adult 3 Photo ID #

Adult 3 Age

Auto Calculates

Month(s)

Adult 4 First and Last Name

Adult 4 Sex M/F

Adult 4 Date of Birth

Adult 4 - Relationship to you

Adult 4 Photo ID #

Adult 4 Age

Auto Calculates

Month(s)

List Information for ALL CHILDREN under 18 living in your household: Date of Birth and SS# will autoformat.

Child 1 First and Last Name

Child 1 Sex M/F

Child 1 Date of Birth

Child 1 - Relationship to you

Child 1 Age

Auto Calculates

Month(s)

Child 2 First and Last Name

Child 2 Sex M/F

Child 2 Date of Birth

Child 2 - Relationship to you

Child 2 Age

Auto Calculates

Month(s)

Child 3 First and Last Name

Child 3 Sex M/F

Child 3 Date of Birth

Child 3 - Relationship to you

Child 3 Age

Auto Calculates

Month(s)

Child 4 First and Last Name

Child 4 Sex M/F

Child 4 Date of Birth

Child 4 - Relationship to you

Child 4 Age

Auto Calculates

Month(s)

Child 5 First and Last Name

Child 5 Sex M/F

Child 5 Date of Birth

Child 5 - Relationship to you

Child 5 Age

Auto Calculates

Month(s)

Child 6 First and Last Name

Child 6 Sex M/F

Child 6 Date of Birth

Child 6 - Relationship to you

Child 6 Age

Auto Calculates

Month(s)

Child 7 First and Last Name

Child 7 Sex M/F

Child 7 Date of Birth

Child 7 - Relationship to you

Child 7 Age

Auto Calculates

Month(s)

Where do you live:(Required)

Do you currently receive assistance through DHA/Sec 8:(Required)

Apt/Condo/Motel name:(Required)

Apt Number

Landlord Name:(Required)

Phone: (this field autoformats)(Required)

One month's rent is? *$(Required)

Move-in Date(Required)

(date you moved on to property -this field autoformats)

Time lived at Residence:

Auto Calculates

Month(s)

How many are on Medicaid?(Required)

How many are on SNAP (food stamps, use numbers)(Required)

Monthly Amount from SNAP $

HOUSEHOLD INCOME INFORMATION - You will be required to provide proof of your income and all working individuals in the residence. You will need to send 2 paystubs for your current employer(s). We require current consecutive paystubs. Employers do not count if you are no longer employed at that company.

Source of Your Income?(Required)

Your Monthly Net Income $(Required)

(take home amount)

Total HOUSEHOLD Monthly Net Income?*$(Required)

(Auto calculating field)

You must have CURRENT income to receive NDSM financial assistance

Your Current Employer's Name:(Required)

Phone: (this field will autoformat)

Your Current Employment Length or length you are receiving your form of income? (example: 6 weeks, 7 months, years) only enter #'s in this box*(Required)

Days, Weeks, Months, Years:*(Required)

Other Monthly Income? $

(take home amount)

Select One

Other Monthly Income? $

(take home amount)

Select One

ADDITIONAL PERSON'S INCOME INFORMATION - You are required to complete this information for Room mates, husbands/wife, boyfriend/girlfriend or any other individual living at the address listed on the application.

Anyone Else in Household Generating Income:(Required)

Source of Additional Person's Income?(Required)

Additional Person's Monthly Net Income $(Required)

(take home amount)

Additional Person's Current Employer's Name:(Required)

Additional Person's Employers Phone: (this field will autoformat)(Required)

Additional Person's Current Employment Length? (example: 6 weeks, 7 months, years)*(Required)

Days, Weeks, Months, Years:*(Required)

Additional Person's Other Monthly Income? $

(take home amount)

Select One

Additional Person's Other Monthly Income? $

(take home amount)

Select One

FINANCIAL ASSISTANCE NEEDED

What kind of help do you need?(Required)

Amount you owe for Rent *$(Required)

Amount you owe for Utilities $(Required)

Brief explanation of why you need this help? (Reason that caused you to be behind) If you fail to tell us reason for your emergency then your request maybe closed.(Required)

A RESPONSE WILL BE EMAILED TO YOU WITHIN 2-4 DAYS ONCE YOU SUBMIT.

IF YOU FAIL TO READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS YOUR APPLICATION CAN BE CLOSED WITHOUT RESPONSE.

Proof of Current Income - YOU MUST HAVE VERIFIABLE CURRENT INCOME. (Current employer only - past employers do not count) attach current paystubs, dates and names must be visible and document must be readable.

Current Employer - Most Recent Paystub Received

Accepted file types: jpg, png, pdf, doc, Max. file size: 100 MB.

Current Employer- Paystub Received right before the one you attached to left.

Accepted file types: jpg, png, pdf, doc, Max. file size: 100 MB.

Other income is proof of any of the following: additional jobs, Unemployment payments, SSI/SSDI, child support, Retirement payments, spouses or roommate's paystubs, etc. - Do not email blank pages of documents.

Proof of any Other Type of Income

Accepted file types: jpg, png, pdf, doc, Max. file size: 100 MB.

Utility Bill

Accepted file types: jpg, png, pdf, doc, Max. file size: 100 MB.

If you send your lease agreement, only send the page that tells the monthly rent and who resides in the home, as well as the move in date. Do not attach or email complete lease. - Do not email blank pages of documents.

Lease

Accepted file types: jpg, png, pdf, doc, Max. file size: 20 MB.

You must have income to receive NDSM financial assistance

Comments

This field is for validation purposes and should be left unchanged.

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