{"id":2582,"date":"2021-10-04T16:42:10","date_gmt":"2021-10-04T16:42:10","guid":{"rendered":"https:\/\/www.region12cog.org\/?page_id=2582"},"modified":"2023-03-14T19:11:51","modified_gmt":"2023-03-14T19:11:51","slug":"waiting-list-application","status":"publish","type":"page","link":"https:\/\/region12cog.org\/waiting-list-application\/","title":{"rendered":"Waiting List Application"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2580-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/2582#wpcf7-f2580-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2580\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2580-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p>Dear Applicant,<br \/>\nPlease note that this is not a guarantee of grant funds. Household income will be verified to meet certain program requirements. Home-owners insurance, property taxes, and utility payments must be current. Limits on assistance apply. We will contact you as funding becomes available. If you have any questions, contact Region XII COG at 712-792-9914.\n<\/p>\n<p><label> Full name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"full-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"full-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Street address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"street-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"street-address\" \/><\/span> <\/label>\n<\/p>\n<p><label> P.O. Box<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"po-box\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"po-box\" \/><\/span> <\/label>\n<\/p>\n<p><label> City and county where your home is located<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"city-county\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city-county\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"phone\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Do you own your home?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"own-home\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"own-home[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"own-home[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Number of all children and adults living in the home?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"children-adults\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"children-adults\" \/><\/span> <\/label>\n<\/p>\n<p><label> Estimate gross annual income from all sources?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"annual-income\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"annual-income\" \/><\/span> <\/label>\n<\/p>\n<p><label> Is anyone in your household over the age of 62?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"over-62\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"over-62[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"over-62[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Is anyone in your household mentally\/physically disabled?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"disabled-residents\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"disabled-residents[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"disabled-residents[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Is anyone in your household a Veteran?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"veteran\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"veteran[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"veteran[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Describe your home repair\/rehabilitation needs (e.g. roof, furnace, air conditioning, etcs.)?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"needs\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"needs\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"_links":{"self":[{"href":"https:\/\/region12cog.org\/wp-json\/wp\/v2\/pages\/2582"}],"collection":[{"href":"https:\/\/region12cog.org\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/region12cog.org\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/region12cog.org\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/region12cog.org\/wp-json\/wp\/v2\/comments?post=2582"}],"version-history":[{"count":3,"href":"https:\/\/region12cog.org\/wp-json\/wp\/v2\/pages\/2582\/revisions"}],"predecessor-version":[{"id":2592,"href":"https:\/\/region12cog.org\/wp-json\/wp\/v2\/pages\/2582\/revisions\/2592"}],"wp:attachment":[{"href":"https:\/\/region12cog.org\/wp-json\/wp\/v2\/media?parent=2582"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}