Emergency Services Client Application

Bus passes are first come first served at our offices please visit the Services Homepage for more information.

For services including eviction prevention, utility assistance, mortgage or rent assistance, the first step is to complete this online application. These services are only available to qualified applicants residing in Delaware County, Ohio.

Please note:
You will be asked to upload documents at the end of this application. Please have these documents ready:
For all applications: photo ID, 60 days income verification
Utilities: bill at disconnect status
Eviction Prevention: lease agreement, 3-day eviction notice letter
Mortgage Assistance: mortgage statement with payment coupon
Due to the nature and focus of our programs, those requesting eviction prevention must have an eviction notice from a landlord, and those requesting utility assistance must have a shut-off notice.

* indicates required field

GENERAL INFORMATION

First Name *

Last Name *

Date of Birth *

Last four digits of SSN *

Phone *

Email *

Address 1 *

Address 2

City *

State *

Zip *

HOUSEHOLD MEMBERS

Number of Household Members *

HOUSEHOLD MEMBER #1 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #2 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #3 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #4 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #5 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #6 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #7 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #8 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #9 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

HOUSEHOLD MEMBER #10 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

Assistance

What type of assistance are you in need of?

Water
Electric
Gas
Eviction Prevention - rent
Mortgage Assistance - home owners

Do you have a utility disconnect or 3-day eviction notice? *
How were you referred to PIN? *
Please write the name of the Agency, if you have had previous PIN assistance, or other referral.

Total Monthly Household Income

Please include all wage earners in the household in the following monthly income fields.

If you do not receive a particular form of income, please enter only the digit 0 in the field.

Are any ADULT household members employed? *

How many people in your household have income? *

Monthly Employment Income *

Unemployment Benefits/Worker's Comp *

Court Ordered Child Support - Received *
Including regular and irregular payments. Please enter 0 if you do not receive Child Support.

Social Security Income/Benefits *

Social Security Disability *

Other Income *
Including veterans benefits, pension, retirement, etc.

SNAP Benefits / Food stamps *

Total annual household income *

Housing

Do you pay rent or mortgage? *

Payment per month *

Are you seeking rental assistance? *

Utilities & Monthly Expenses

In this section, please provide your best guess at a monthly average for each of these expenses. If you do not pay for a particular service, please input a 0 in the field.

Heating *
Gas, fuel oil, propane, wood/coal

Electric *

Water *

Telephone/cell service *

Food *

Taxable groceries *
Taxable groceries are items like toilet paper, shampoo, soap, cigarettes, diapers, and pet food.

Gasoline *

Childcare *

Child support (that you pay out) *

Medical/dental *
Include prescriptions, co-pays, office visit expenses.

Vehicle payment *

Insurance *
Insurance expenses include life, home, rental, auto, and medical.

Credit card/credit union *

Loans/rental items *

Cable/internet/satellite service *

Other *
Miscellaneous expenses not mentioned above.

Significant circumstances *
Please explain the emergency situation which led you to apply for assistance.

Eligibility

ANY FALSIFICATION OF INFORMATION PROVIDED ON THESE FORMS WILL AUTOMATICALLY DISQUALIFY YOU FROM ELIGIBILITY FOR ANY ASSISTANCE FROM PEOPLE IN NEED, INC. (PIN).

As required by Section 2.32 (a), Prohibition on re-disclosure - Rules.

This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person or persons to whom it pertains, or as otherwise permitted by such regulations. A general authorization from the release of medical or other information is NOT sufficient for this purpose.

Authorization

NOTE: All matters relating to client records are considered privileged and confidential and are treated as such by the employees of the Program. Information regarding such matters cannot be divulged without the consent of the client. Section 2.31 of P.L. 93-282.42 CFR. Part 2 requires the following information.

PEOPLE IN NEED, INC. OF DELAWARE COUNTY OHIO is hereby granted my permission to release to appropriate agencies, such information deemed necessary to facilitate my request for Emergency Assistance and collect necessary information from those appropriate agencies.

Signature *

You will be asked to upload the supporting documentation for this application next.