Housing Assistance Request Form

To receive information regarding our Down Payment Assistance Program, fill out the form below COMPLETELY and we will be in touch with you to discuss the possibilities of home ownership.


First and Last Name (required)

Active Email Address (required)

Phone Number

Address, City, State Zip

County of Residence


Please select one of the following options:

I need help regarding Foreclosure Prevention.I need help with Pre-Purchase and/or Educational Counseling.I need help with Financial Literacy and/or Budget/Credit Counseling.I need help regarding Fair Housing Practices.None of these. I need basic referral information, miscellaneous housing information, or something else.

Additional details or comments:

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  • Ashtabula
  • Office of Social Services
  • Regional Agency
  • Portage & Stark