ACCESS Housing Direct Assistance Form(Head of Household Info)
Thank you for filling out an application for assistance with ACCESS Housing. Our application opens the beginning of each month and closes the 10th of each month. We will reach out to families in 15 business days does not include Fridays, Saturdays, Sunday or Holidays . Due to high demand for assistance we can not look up your application to see if we have received or not.

PLEASE DONT SUBMIT MORE THEN ONE APPLICATION. SUBMITTING MORE THEN ONE APPLICATION WILL MAKE YOUR APPLICATION DENIED.

SHORT ANSWER IN THE DESCRIPTION BOX CAN MAKE YOUR APPLCATION DENIED PLEASE MAKE SURE YOU DESCRIPE WHY YOU ARE NEEDING ASSISTNANCE.

MAKE SURE YOU FILL OUT THE WHOLE APPLICATION, BECAUSE MISSING PARTS OF THE APPLICATION CAN HOLD OR DENY YOUR APPLICATION.

ALSO KEEP IN MIND WE ARE NOT IN THE OFFICE ON FRIDAY thru SUNDAY.

AFTER YOU SUMBIT THE APPLICATION, IT CAN TAKE UP TO 15 BUSINESS DAYS BEFORE YOU WILL GET AN EMAIL BACK STATING YOU ARE APPROVED OR DENIED.  PLEASE MAKE SURE YOU LOOK IN YOUR EMAILS. WE DO NOT COUNT FRIDAYS THROUGH SUNDAY OR HOLIDAYS AS BUSSINESS DAYS.

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ACCESS Housing Direct Assistance Form(Head of Household Info)
Name (First and Last name) *
Address *
City, State and zip *
Email address *
Phone Number *
Do you reside in Adams County? (Must reside in Adams County to receive assistance) *
Type of Assistance Requesting. *
Required
Is this COVID Related/COVID Impacted (If Yes, you will have to prove it if approved for assistance) *
Have you already received assistance from us this year?(We can only provide assistance once every 12 months) *
What month do you need assistance? Only one can be selected. We will not assist with the previous month of next month. (ONLY HELP WITH ONE MONTH) *
Please Provide a description of what type of assistance you need help with and why? (IF YOUR DESCRIPTION DOES NOT HAVE ENOUGH INFORMATION, THE APPLICATION PROCESS WILL BE STOPPED AND YOU WILL NEED TO REAPPLY NEXT MONTH.) *
Household Size *
Birth Date *
MM
/
DD
/
YYYY
Age *
Gender *
Race *
Ethnicity *
Are you a veteran? *
Disabling Condition *
If Yes to Disabling Condition, Please describe *
How many adults in the household?  (Living in the household) *
How many dependents in the household? (children  living in the household) *
What is the amount of your monthly rental/mortgage payment? (Pay every month) *
What is the total amount you currently owe? (As of today) *
Do you have a notice of eviction or foreclosure? *
Utility Assistance: What is the total amount you currently owe? (As of today) *
Do you have a notice of disconnection? *
Monthly Household Income (Per a Month) *
Sources of Income(Check all that apply and write amount you receive each month for each source) *
Required
Non-Cash Benefits(choose all that apply) *
Required
Client Signature(By signing this form, I hereby agree the information stated in my application is accurate to the best of my knowledge) *
Date *
MM
/
DD
/
YYYY
Submit
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