Your Name

Middle Initial

Last Name

Your Address

Address Line 2 (Apt. number) Optional

City

State

Zip Code

Phone Number

Email

Secondary Contact Information

Date of Birth

Race
—Please choose an option—WhiteBlack or African AmericanAsianNative Hawaiian and other Pacific IslanderTwo or more racesOther, please specify

Are you Hispanic or Latino?

YesNo

Gender Identity

WomanManNon-binaryPrefer not to sayOther

If other, please specify

Are you a refugee or asylee?

YesNo

How many family members are currently living in your household?

Please list each household member, their gender, and age. Example: Mary Smith, F, 18

Why are you in need of this assistance?

Are you currently employed?
—Please choose an option—YesNoReceiving Disability InsuranceReceiving Retirement BenefitsOther

How many sources of income do you have in your household?

What is your household monthly income?

What is your total individual yearly income?

Are you requesting rental assistance?

YesNo

What is your current living situation?

Do you:
—Please choose an option—RentOwnLease to ownRent from familyParticipate in Section 8Participate in Section 42SubleaseWithout a ContractOther

Have you received help from other rent relief programs? (such as Community action, YWCA, Housing authority)

What years and months?

Are you facing any of these difficulties:
Currently behind rentReceived an eviction noticeCurrently unshelteredAccumulated late feesOther

Why are you behind on this bill? - If you experienced temporary unemployment or loss of income, please state the nature of the situation.

How much do you need to be current on this bill?

Are you behind any other bills?

How did you hear about us?