Jewish Family Service Financial Assistance 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 Are you behind any other bills? How did you hear about us? For more information on emergency financial assistance, please call 801-746-4334.