DMPM Pre-Application

Thank you for your interest in our Housing Programs. Once you have submitted your pre-application, it is very important you notify our office, in writing, if your correspondence address changes so we can contact you when you reach the top of the wait list.

We do not advise submitting this information via the web site so please turn in verification of Social Security numbers for all household members to our administrative office within thirty days of submitting your electronic pre-application.

The Pre-Application is comprised of the following four sections along with a certification statement. If you need assistance completing this form, please contact our office at 541-673-6548.

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Program Selection

Contact Information

First Name *

Last Name *

Physical Street Address *

Mailing Address *

City *

State *

Zip Code *

Phone Number

Please enter area code XXX-XXX-XXXX

e-mail address

Does this household require wheelchair accessibility?

Yes

Household Member Information

Gross Household Income Per Year *

Number of household members *

1. Head of Household (HOH) Name *

HOH Birthdate *

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HOH Gender *

Male

Female

HOH Disability Status

I have a disability. I have a physical or mental impairment that substantially limits one or more major life activities or I have a record if such impairment.

HOH Ethnicity

Hispanic

Non-Hispanic

I decline to report

2. Household Member #2 (HM #2) Name

HM #2 Birthdate

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HM #2 Gender

Male

Female

HM #2 Disability Status

I have a disability. I have a physical or mental impairment that substantially limits one or more major life activities or I have a record if such impairment.

HM #2 Ethnicity

Hispanic

Non-Hispanic

I decline to report

3. Household Member #3 (HM #3) Name

HM #3 Birthdate

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HM #3 Gender

Male

Female

HM #3 Disability Status

I have a disability. I have a physical or mental impairment that substantially limits one or more major life activities or I have a record if such impairment.

HM #3 Ethnicity

Hispanic

Non-Hispanic

I decline to report

4. Household Member #4 (HM #4) Name

HM #4 Birthdate

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HM #4 Gender

Male

Female

HM #4 Disability Status

I have a disability. I have a physical or mental impairment that substantially limits one or more major life activities or I have a record if such impairment.

HM #4 Ethnicity

Hispanic

Non-Hispanic

I decline to report

5. Household Member #5 (HM #5) Name

HM #5 Birthdate

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HM #5 Gender

Male

Female

HM #5 Disability Status

I have a disability. I have a physical or mental impairment that substantially limits one or more major life activities or I have a record if such impairment.

HM #5 Ethnicity

Hispanic

Non-Hispanic

I decline to report

6. Household Member #6 (HM #6) Name

HM #6 Birthdate

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HM #6 Gender

Male

Female

HM #6 Disability Status

I have a disability. I have a physical or mental impairment that substantially limits one or more major life activities or I have a record if such impairment.

HM #6 Ethnicity

Hispanic

Non-Hispanic

I decline to report

7. Household Member #7 (HM #7) Name

HM #7 Birthdate

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edit-submitted-individual-household-member-information-hm7-birthdate-year

HM #7 Gender

Male

Female

HM #7 Disability Status

I have a disability. I have a physical or mental impairment that substantially limits one or more major life activities or I have a record if such impairment.

HM #7 Ethnicity

Hispanic

Non-Hispanic

I decline to report

Certification *

I certify that I have given true and complete information and I understand I must provide verification of Social Security Numbers for every household member.

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