PDF Print

Criminal History Form

 

Please print all nine (9) pages of form and complete as directed for all family members 18 years and older who are listed on the Pre-Application form.

 

Your completion of this form must be Printed Legibly. Your Full Name and Date of Birth must be the same as on your current Government ID or Driver's License. Your Social Security Number must be the same as on your social security card.

 

Upon completion of the form(s), you have the following options to return it to OHA.

  • Fax 402-546-1069 Attention Intake
  • Hand deliver or mail to OHA, Attention Intake, 1805 Harney Street, Omaha NE 68102
    (Please use the side entrance on 18th Street if hand delivering the forms)
  • E-mail (non-secure) to This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Criminal history form(s) should be submitted within five (5) days of submission of the Pre-Application form. Processing cannot begin until both the Pre-Application form and Criminal History forms are received.

 

Criminal History Form