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To learn more about your email Add-On options, visit the Gravity Forms Add-Ons page.Today's Date Property Owner InformationApplicant Name* First Last Preferred Language*EnglishSpanishAmharicArabicBurmeseChineseDariDinkaFarsiFrenchGermanKarenKarenniKikongoKinyarwandaKirundiLingalaLugandaNepaliPashtoSomaliSwahiliVietnameseApplicant Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*DouglasSarpyAdamsAntelopeArthurBannerBlaineBooneBox ButteBoydBrownBuffaloBurtButlerCassCedarChaseCherryCheyenneClayColfaxCumingCusterDakotaDawesDawsonDeuelDixonDodgeDundyFillmoreFranklinFrontierFurnasGageGardenGarfieldGosperGrantGreeleyHallHamiltonHarlanHayesHitchcockHoltHookerHowardJeffersonJohnsonKearneyKeithKeya PahaKimballKnoxLancasterLincolnLoganLoupMadisonMcPhersonMerrickMorrillNanceNemahaNuckollsOtoePawneePerkinsPhelpsPiercePlattePolkRed WillowRichardsonRockSalineSaundersScotts BluffSewardSheridanShermanSiouxStantonThayerThomasThurstonValleyWashingtonWayneWebsterWheelerYorkInsurance typeMedicaidMedicareAffordable Care Act (ACA)PrivateSelf PayVeteran's Administration (VA)COBRAOtherContact InformationApplicant Phone*Applicant 2nd Phone*Applicant Email Do you have a co-applicant?* Yes NoCo-Applicant Name* First Last Phone*How Can We Reach You?We are so excited about your interest in the Healthy Housing Program. Please let us know how best to contact you.Preferred Methods of Contact* Phone call Email TextHOUSEHOLD MEMBERS & INCOMEPlease list all household members who are living at this address. Please list all household income for adults over 18 who are not full time students. NOTE: Do NOT click the "+" sign.1- Head of Household* Add Remove1- Date of Birth* 1- Race/Ethnicity*American Indian or AlaskanAsianBlack or African AmericanHawaiian/Pacific IslanderHispanic/LatinoMiddle Eastern/North AfricanNon-Hispanic/LatinoWhiteUnknownOtherDecline1- Relationship to Applicant*Applicant/SelfHusbandWifeSonFoster SonDaughterFoster DaughterFatherMotherGrandmotherGrandfatherAuntUncleBrotherSisterFriend1- Disability* Yes No1- Please enter your annual income*Do you have a 2nd person living in the house?* Yes No2- Household Member* Add Remove2- Date of Birth* 2- Race/Ethnicity*American Indian or AlaskanAsianBlack or African AmericanHawaiian/Pacific IslanderHispanic/LatinoMiddle Eastern/North AfricanNon-Hispanic/LatinoWhiteUnknownOtherDecline2- Relationship to Applicant*Applicant/SelfHusbandWifeSonFoster SonDaughterFoster DaughterFatherMotherGrandmotherGrandfatherAuntUncleBrotherSisterFriend2- Disability* Yes No2- Please enter your annual income*Do you have a 3rd person living in the house?* Yes No3- Household Member* Add Remove3- Date of Birth* 3- Race/Ethnicity*American Indian or AlaskanAsianBlack or African AmericanHawaiian/Pacific IslanderHispanic/LatinoMiddle Eastern/North AfricanNon-Hispanic/LatinoWhiteUnknownOtherDecline3- Relationship to Applicant*Applicant/SelfHusbandWifeSonFoster SonDaughterFoster DaughterFatherMotherGrandmotherGrandfatherAuntUncleBrotherSisterFriend3- Disability* Yes No3- Please enter your annual income*Do you have a 4th person living in the house?* Yes No4- Household Member* Add Remove4- Date of Birth* 4- Race/Ethnicity*American Indian or AlaskanAsianBlack or African AmericanHawaiian/Pacific IslanderHispanic/LatinoMiddle Eastern/North AfricanNon-Hispanic/LatinoWhiteUnknownOtherDecline4- Relationship to Applicant*Applicant/SelfHusbandWifeSonFoster SonDaughterFoster DaughterFatherMotherGrandmotherGrandfatherAuntUncleBrotherSisterFriend4- Disability* Yes No4- Please enter your annual income*Do you have a 5th person living in the house?* Yes No5- Household Member* Add Remove5- Date of Birth* 5- Race/Ethnicity*American Indian or AlaskanAsianBlack or African AmericanHawaiian/Pacific IslanderHispanic/LatinoMiddle Eastern/North AfricanNon-Hispanic/LatinoWhiteUnknownOtherDecline5- Relationship to Applicant*Applicant/SelfHusbandWifeSonFoster SonDaughterFoster DaughterFatherMotherGrandmotherGrandfatherAuntUncleBrotherSisterFriend5- Disability* Yes No5- Please enter your annual income*Do you have a 6th person living in the house?* Yes No6- Household Member* Add Remove6- Date of Birth* 6- Race/Ethnicity*American Indian or AlaskanAsianBlack or African AmericanHawaiian/Pacific IslanderHispanic/LatinoMiddle Eastern/North AfricanNon-Hispanic/LatinoWhiteUnknownOtherDecline6- Relationship to Applicant*Applicant/SelfHusbandWifeSonFoster SonDaughterFoster DaughterFatherMotherGrandmotherGrandfatherAuntUncleBrotherSisterFriend6- Disability* Yes No6- Please enter your annual income*Do you have a 7th person living in the house?* Yes No7- Household Member* Add Remove7- Date of Birth* 7- Race/Ethnicity*American Indian or AlaskanAsianBlack or African AmericanHawaiian/Pacific IslanderHispanic/LatinoMiddle Eastern/North AfricanNon-Hispanic/LatinoWhiteUnknownOtherDecline7- Relationship to Applicant*Applicant/SelfHusbandWifeSonFoster SonDaughterFoster DaughterFatherMotherGrandmotherGrandfatherAuntUncleBrotherSisterFriend7- Disability* Yes No7- Please enter your annual income*Do you have an 8th person living in the house?* Yes No8- Household Member* Add Remove8- Date of Birth* 8- Race/Ethnicity*American Indian or AlaskanAsianBlack or African AmericanHawaiian/Pacific IslanderHispanic/LatinoMiddle Eastern/North AfricanNon-Hispanic/LatinoWhiteUnknownOtherDecline8- Relationship to Applicant*Applicant/SelfHusbandWifeSonFoster SonDaughterFoster DaughterFatherMotherGrandmotherGrandfatherAuntUncleBrotherSisterFriend8- Disability* Yes No8- Please enter your annual income* Property InformationType of Property*Single-FamilyMulti-Family UnitPlease select the type of property.If it's a multi-family unit, how many units are there?Do you currently have a mortgage? Yes NoSection 8 Housing* Yes NoHousing Authority*Omaha Housing AuthorityDouglas Housing AuthorityOtherHow did you hear about us or what agency referred you?*What are your concerns about your home?*Do you have any pests (roaches, mice, bedbugs, fleas, etc.) currently in your home? Yes NoPlease CLICK on every pest that is currently in your home. Roaches Mice Bedbugs Fleas Other INDEMNIFICATION. The Client agrees to indemnify, defend, and hold harmless Healthy Housing Omaha, including its board of directors, officers, employees, agents, and affiliates (collectively, the "Indemnified Parties"), from and against any and all claims, liabilities, damages, losses, costs, expenses (including reasonable attorneys' fees), judgments, fines, and penalties arising out of or related to the Client's use of Healthy Housing Omaha's services. This indemnity covers, but is not limited to, any damages or liability arising from the Client's breach of this Agreement, negligence, willful misconduct, or any other action by the Client that results in harm or liability. The Indemnified Parties shall not be liable for any indirect, special, incidental, consequential, or punitive damages, including lost profits, arising out of or in connection with this Agreement or the services provided hereunder. The Client's obligation to indemnify the Indemnified Parties shall survive the termination or expiration of this Agreement."Signatures- By typing in your name, today's date, and clicking "Submit", you agree that all the information is true to the best of your knowledge. I understand that completing the application process is no guarantee of receiving funding.Are you filling this form out on behalf of someone other than yourself?* Yes NoName of individual completing application on behalf of applicant.* First Last Organization*Job Title*Email* Phone*Name of Applicant* First Last Is there a co-applicant?* Yes NoName of Co-Applicant* First Last Signature*Date*