Turn off notice example – Community Action Council of Howard County

Each service year, CAC is required to collect new information from returning clients requesting additional services. Even though you may have answered many of these questions in a prior form, your most recent information could be different. Information about household income, household members, and even home address, phone numbers and email change occasionally. To make sure we can process your request as quickly as possible, we ask that you complete a new Universal Application each service year. CAC’s service year starts on July 1st of each year.

Please click the link below to complete your application.

Thank you for your understanding.

Community Action Council of Howard County

- Step 1 of 2

Holland Awards Event *

General Admission Tickets ($100/ticket)
First Responders Tickets ($65/ticket)
Cannot attend but want to contribute

Number of General Admission Tickets *

Number of First Responder Tickets *

*These tickets are for first responders and their guests only.

Attendee(s) Name & Email

Please list the name and email addresses of all attendees, if available.

Amount to Donate *

Would you like to make a donation to support CAC? If so, please enter amount below.

Total

$ 0.00

You are registering/giving as an: *

Business/Organization Name *

Business/Organization Type *

Name *

First

Middle

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Total

$ 0.00

Send All emails to this address

Village of Supporters

- Step 1 of 2

VoS Sponsorship/Membership Level: *

CAC Intrapreneur - $ 10,000.00
CAC Champion - $ 5,000.00
CAC Advocate - $ 2,500.00
CAC Partner - $ 1,000.00
CAC Friend - $ 500.00

You are sponsoring as: *

Business/Organization Name *

Business/Organization Type *

Name *

First

Middle

Last

Email *

Phone

Address

Address Line 1

City

State

Zip Code

Total

$ 0.00

Send All emails to this address

Landlord Intake Form

- Step 1 of 3

Please provide some information about the property.

Contact Information

Landlord or Property Manager's Name *

First

Last

Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

Property Information

Property Name (or Tenant Name)

Property Address *

Address Line 1

City

State

Zip Code

County *

Number of Units *

Housing Type

Single-family Home
Duplex/Townhouse
Mobile Home
Condo
Apartment
Mixed Housing Complex

Do you know if any of your tenants are receiving the following? Check all that apply.

OHEP Utility Bill Pay Assistance
Housing Choice Vouchers (HUD)
Supplement Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
Supplemental Security Income (SSI)
Medicaid
Maryland Fuel Fund Assistance
DHCD Rehab Program
Baltimore Lead Hazard Control Program
I don’t know
Healthy Homes for Healthy Kids

Does the property have any of the following problems? Check all that apply.

Missing or broken windows or external doors
Mold or mildew
Active roof leaks
Any damage to ceilings
Electrical violations or hazards
None of the above
Plumbing leaks, moisture problems

Are there any other health, safety or structural conditions in the home you would like to address? Please explain below.

Would you like to add another property?

Property Information (#2)

Property Name (or Tenant Name)

Property Address *

Address Line 1

City

State

Zip Code

County *

Number of Units *

Housing Type

Single-family Home
Duplex/Townhouse
Mobile Home
Condo
Apartment
Mixed Housing Complex

Do you know if any of your tenants are receiving the following? Check all that apply.

OHEP Utility Bill Pay Assistance
Housing Choice Vouchers (HUD)
Supplement Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
Supplemental Security Income (SSI)
Medicaid
Maryland Fuel Fund Assistance
DHCD Rehab Program
Baltimore Lead Hazard Control Program
I don’t know
Healthy Homes for Healthy Kids

Does the property have any of the following problems? Check all that apply.

Missing or broken windows or external doors
Mold or mildew
Active roof leaks
Any damage to ceilings
Electrical violations or hazards
None of the above
Plumbing leaks, moisture problems

Are there any other health, safety or structural conditions in the home you would like to address? Please explain below.

Updating preview…

This is a preview of your submission. It has not been submitted yet!
Please take a moment to verify your information. You can also go back to make changes.

Weatherization Intake Form

- Step 1 of 5

Please provide some basic information about your home. This form is not a substitute for a full application. A Weatherization staff member will let you know if a full application is needed.

Client Information

Name *

First

Last

Phone *

Address *

Address Line 1

City

State

Zip Code

County *

Email *

Property Information

I am a: *

Homeowner
Renter

I live in a: *

Single-Family Home
Duplex/Townhouse
Mobile Home
Condo
Apartment

I have an eviction or foreclosure notice: *

Do you currently receive any of the following? Check all that apply.

Housing Choice Vouchers (HUD)
OHEP Utility Bill Pay Assistance
Supplement Nutrition Assistance Program (SNAP)
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (TANF)
Maryland Fuel Fund Assistance
Medicaid
DHCD Rehab Program
Baltimore Lead Hazard Control Program
Healthy Homes for Healthy Kids

Energy Services & Prior Weatherization

I applied for Utility Assistance: *

Within the last month
Within in the past year
Never / More than a year ago

I have received a letter from: *

OHEP Office of Home Energy Program and/or
DHCD Department of Housing and Community Development
Did not receive a letter

Date you received letter:

I have had Weatherization in the past: *

If yes, how long ago and what did they do?

Weatherization Services

What do you think your home needs? Check all that apply.

LED light bulbs
Insulation in attic or basement
Programmable thermostat
Showerheads
Clean & tune heating or cooling units
Adjust refrigerator and hot water temperatures
Clean refrigerator coils
Caulking around windows & doors
Smoke & carbon monoxide detectors
New appliances

If you selected "New Appliances" above, please indicate which one(s):

Refrigerator
Clothes Washer
Clothes Dryer

Appliances

My water heater is working: *

My refrigerator is working: *

Cooling

How do you cool your home? *

Central AC
Window AC
None

My AC is working: *

Electric

My electric company is: *

I have a turn off notice from this company / My service is turned off: *

Heating

What is the main heating source of your home? *

Electricity
Gas
Propane
Oil
Wood

My heat is currently working: *

My heat supplier or fuel company is: *

I have a turn off notice from this company / My service is turned off: *

Structural Condition of Home

My house has the following issue(s): *

Missing or broken windows or external doors
Mold or mildew
Active roof leaks
Any damage to ceilings
Electrical violations or hazards
Plumbing leaks, moisture problems
Other health, safety, or structural conditions in your home
None of the above

If you have any other information or concerns about your home, please list them here:

Updating preview…

This is a preview of your submission. It has not been submitted yet!
Please take a moment to verify your information. You can also go back to make changes.

Donate

Donation Amount *

$ 50
$ 100
$ 250
$ 500
Other

Other Donation Amount *

Recurrence *

One Time
Monthly

Name *

First

Last

Is the name on the credit card you are using the same as the name above? *

Name on Credit Card *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Additional Information

Total

$ 0.00

The field below is temporary for testing purposes. Fill out the email field with YOUR email address to see what the emails look like.

Send Donor and CAC email to this address

Donate - One Months Rent

Donation Amount *

$ 50
$ 100
$ 250
$ 500
Other

Other Donation Amount *

Recurrence *

One Time
Monthly

Name *

First

Last

Is the name on the credit card you are using the same as the name above? *

Name on Credit Card *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Additional Information

Total

$ 0.00

The field below is temporary for testing purposes. Fill out the email field with YOUR email address to see what the emails look like.

Send Donor and CAC email to this address

SNAP - Request for Application Assistance

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Date of Birth *//

Gender *

Male
Female

Have you received SNAP benefits in the past 2 years? *

Management Company	Property Name
Apartment Services, Inc.	Lawyers Hill
AvalonBay Communities	Avalon Fairway Hills, Eaves Columbia Town Center
Enterprise Residential	Community Homes Housing, Inc., Owen Brown Place, Park View at Ellicott City I & II, Sierra Woods, Forest Ridge, Hickory Ridge Place, Park View at Columbia, Harper House, Park View at Colonial Landing, Park View at Snowden River, Park View at Emerson, Waverly Winds, Roslyn Rise, Fall River Terrace, Ranleagh Court
Fieldstone Properties	Columbia Choice, Stonehaven
Gates, Hudson & Assoc	Columbia Glade, Ashbury Courts
GoldOller Real Estate Investments	Seasons
Greystar	Sherwood Crossings, Columbia Town Center, Paragon at Columbia Overlook, Ellicott Grove, Madison at Eden Brook, Poplar Glen, Hamilton at Kings Place, Beech’s Farm
Greystar Management	The Juniper, The Hamilton
Harbor Group Management Co.	Howard Crossing
Hendersen-Webb, Inc	Bluffs at Clary’s Forest, Bluffs at Hawthorn, Bluffs at Fairway Hills
Maryland Management	Harpers Forest
Mill Creek Residential Trust LLC	Alister Town Center Columbia, Alister Columbia
Morgan Properties	Charleston Place, Columbia Pointe, Grand Pointe, Orchard Meadows, Orchard Meadows at North Ridge
Murn Management	Brook at Columbia, The Brooks, Dartmoore Place at Oxford Square, Brompton House at Blue Stream, Brompton House at Blue Stream I, The Refinery, Brompton House at Blue Stream II, Brompton House East, Townes at Pine Orchard
Pointe Management Group	Clary’s Crossing
Wood Partners	Orchard Park I, II & III, Kaiser Park, Penniman Park
Wood Residential Services	The Wexley at 100, Alta at Regency Crest Apartments

Management Company	Property Name
Apartment Services, Inc.	Lawyers Hill
AvalonBay Communities	Avalon Fairway Hills
AvalonBay Communities	Eaves Columbia Town Center
Enterprise Residential	Community Homes Housing, Inc.
Enterprise Residential	Owen Brown Place
Enterprise Residential	Park View at Ellicott City I & II
Enterprise Residential	Sierra Woods
Enterprise Residential	Forest Ridge
Enterprise Residential	Hickory Ridge Place
Enterprise Residential	Park View at Columbia
Enterprise Residential	Harper House
Enterprise Residential	Park View at Colonial Landing
Enterprise Residential	Park View at Snowden River
Enterprise Residential	Park View at Emerson
Enterprise Residential	Waverly Winds
Enterprise Residential	Roslyn Rise
Enterprise Residential	Fall River Terrace
Enterprise Residential	Ranleagh Court
Fieldstone Properties	Columbia Choice
Fieldstone Properties	Stonehaven
Gates, Hudson & Assoc	Columbia Glade
Gates, Hudson & Assoc	Ashbury Courts
GoldOller Real Estate Investments	Seasons
Greystar	Sherwood Crossings
Greystar	Columbia Town Center
Greystar	Paragon at Columbia Overlook
Greystar	Ellicott Grove
Greystar	Madison at Eden Brook
Greystar	Poplar Glen
Greystar	Hamilton at Kings Place
Greystar	Beech’s Farm
Greystar Management	The Juniper
Greystar Management	The Hamilton
Harbor Group Management Co.	Howard Crossing
Hendersen-Webb, Inc	Bluffs at Clary’s Forest
Hendersen-Webb, Inc	Bluffs at Hawthorn
Hendersen-Webb, Inc.	Bluffs at Fairway Hills
Maryland Management	Harpers Forest
Mill Creek Residential Trust LLC	Alister Town Center Columbia
Mill Creek Residential Trust LLC	Alister Columbia
Morgan Properties	Charleston Place
Morgan Properties	Columbia Pointe
Morgan Properties	Grand Pointe
Morgan Properties	Orchard Meadows
Morgan Properties	Orchard Meadows at North Ridge
Murn Management	Brook at Columbia
Murn Management	The Brooks
Murn Management	Dartmoore Place at Oxford Square
Murn Management	Brompton House at Blue Stream
Murn Management	Brompton House at Blue Stream I
Murn Management	The Refinery
Murn Management	Brompton House at Blue Stream II
Murn Management	Brompton House East
Murn Management	Townes at Pine Orchard
Pointe Management Group	Clary’s Crossing
Wood Partners	Orchard Park I, II & III
Wood Partners	Kaiser Park
Wood Partners	Penniman Park
Wood Residential Services	The Wexley at 100
Wood Residential Services	Alta at Regency Crest Apartments