P2Ho-DISASTER RECOVERY APPLICATION

Welcome!

Complete the Enrollment Application by clicking "next" below. On the next page, click on each section to complete the application. The application averages 30-45 minutes, consisting of 5 sections. Please note, if needed, you can save the application and return at a later time.

Welcome to the Program!

Pathways Program Application- Disaster Recovery
Date of Application

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Service Requested
Disaster Relief
How were you referred to us?
Client Name

First NameLast Name
Address at the time of the Disaster

Address

Street Address Line 2

CityState

Postal / Zip Code
Is this your current address?
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live in the City or County?
What neighborhood in the County do you live in?
What neighborhood in the City do you live in?
Gender
Pronouns
LGBTQ+
SSN:
Date of Birth

MonthDayYear
Date
Client Age
Client Age Group
Client Phone Number
Format: (000) 000-0000.
Client Email
example@example.com
Are you a Veteran?
Do you have a disability or long-term condition that affects daily activities? (Physical, Sensory, Mental Health, Chronic Illness, etc.)
Client Race
Client Ethnicity
Marital Status
Current Living Situation?
Total Household #:
How many children do you have UNDER 18 LIVING with you?
Besides yourself, how many adults in the household are between the ages of 18-64?
How many adults 65 and older in the household?

CHILDREN INFORMATION:
Child 1 Name
Child 1 Age
Child 1 Date of Birth

MonthDayYear
Date
Child 1 Gender
Child 1 Race
Child 2 Name
Child 2 Age
Child 2 Date of Birth

MonthDayYear
Date
Child 2 Gender
Child 2 Race
Child 3 Name
Child 3 Age
Child 3 Date of Birth

MonthDayYear
Date
Child 3 Gender
Child 3 Race
Child 4 Name
Child 4 Age
Child 4 Date of Birth

MonthDayYear
Date
Child 4 Gender
Child 4 Race
Child 5 Name
Child 5 Age
Child 5 Date of Birth

MonthDayYear
Date
Child 5 Gender
Child 5 Race
Additional Children (if needed)

Aditional Household Members :
Household Member 1 Name
Household Member 1 Age
Household Member 1 Date of Birth

MonthDayYear
Date
Household Member 1 Gender
Household Member 1 Race
Household Member 2 Name
Household Member 2 Age
Child 2 Date of Birth

MonthDayYear
Date
Household Member 2 Gender
Household Member 2 Race
Household Member 3 Name
Household Member 3 Age
Household Member 3 Date of Birth

MonthDayYear
Date
Household Member 3 Gender
Household Member 3 Race
Household Member 4 Name
Household Member 4 Age
Household Member 4 Date of Birth

MonthDayYear
Date
Household Member 4 Gender
Household Member 4 Race
Household Member 5 Name
Household Member 5 Age
Household Member 5 Date of Birth

MonthDayYear
Date
Household Member 5 Gender
Household Member 5 Race

Missouri Housing Development Commission
MHTF-DR 306

Consent & Housing Status Certification
I understand and acknowledge that Diamond Diva Empowerment Foundation (the "Agency"), in exchange for receiving funds from the Missouri Housing Development Commission ("MHDC"), is required to share certain information about me with MHDC in order to ensure the Agency's compliance with all rules and requirements associated with the distribution of funds from MHDC.
Initial Here
I hereby authorize the Agency to share all of my personal information provided with MHDC, and other state and federal agencies, for the limited purposes of proving that I qualify to receive assistance administered by MHDC to ensure that the Agency is in compliance with the rules and requirements associated with the distribution of funds from MHDC. I further authorize MHDC and all participating funding agencies to contact me directly to discuss any matters related to my receipt of MHDC funds and agree to provide any additional information that MHDC may deem necessary in order to fully determine my eligibility for MHDC funds and/or to determine whether the Agency is in compliance with all rules and requirements of associated with the distribution of funds from MHDC.
Initial Here
Please Indicate the type of supporting materials you have as proof of disaster impact (all selections will require uploaded documentation).
Proof
Housing Condition

Before service can be requested on an existing property or assistance can be provided to move into a new dwelling, you must certify the housing condition based on the following criteria.
Please indicate which of the following statements is most accurate as it pertains to your current housing:
By signing below, I certify that:
- I have insufficient financial resources and support networks, e.g., family, friends, faith-based, other social networks, immediately available to obtain housing or to attain housing stability without assistance; and
- I certify that the information above and any other information I have provided in applying for assistance is true, accurate and complete; and
- I hereby authorize the Agency to share all of my personal information provided with MHDC for the limited purposes of proving that I qualify to receive MHTF-DR funding and ensuring that the Agency is in compliance with the rules and requirements associated with the distribution of MHTF-DR funds.
- Domestic Violence (DV) only: I hereby authorize the Agency to share non-identifying information with MHDC and its auditors for the limited purposes of proving that I qualify to receive the assistance administered by MHDC and ensure that the Agency is in compliance with the rules and requirements associated with the distribution of MHTF-DR funds.
Client Signature

Clear
Initials
Last Four Digits of SSN
2Def
Disaster Recovery RITD
Client Status
Primary Language

Pathways Program Application- Disaster Recovery

CHILDREN INFORMATION:

Aditional Household Members :

Education & Income

Disaster Recovery:

Missouri Housing Development Commission

Housing Condition