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Please complete the following fields to create a Social Services account.
Organization Information
Company, Agency, or Apartment Building:
Address:
DBA, if different:
Management Company, if different:
City:
Main Contact:
State:
Select One
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Connecticut
Delaware
District of Columbia
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Hawaii
Idaho
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Title:
Zip:
Email:
Phone Number:
Ext.
Fax #:
Fax Number to Register
Number:
Date you would like to begin
Start Date (mmddyyyy):
Tax Exemption Status
Is your agency tax exempt?
Yes
No
Agency Type
State or County Social Services/Human Services Agency
Social Security Administration
Work Program (WIA)
Housing Authority
Low-Income Housing (i.e. Sec. 8, Sec.42)
Child Support Enforcement
Third Party Vendor for Government Agency
Other
Specific Programs or Divisions that will use this Service
Food Stamps
TANF
General Cash Advance
Low-Income Energy Assistance
IEVS
Fraud Investigations
Quality Control
Housing Assistance
Title IV-D
Emergency Assistance
Title II
Title XVI
Collections
Pre-employment
Medicaid
Daycare Assistance
Work-related Assistance
Mortgage Loans
Apartment Complex
Other: Please indicate other programs that will use this service:
Apartment/Property Management
If you are an
Apartment Complex
or
Property Management Company
, please answer the following questions:
How many units do you have?
How many of those are subsidized units?
Are you affiliated with a City/State Housing Authority?
Yes
No
If yes, please include the name: