Emergency Rental Assistance Program

Emergency Rental Assistance Program
Tenant Contact Information

If you are a Tenant who has experienced financial hardship meeting housing cost payments due to the COVID-19 Pandemic, please complete this form so your information will be on file with the Rockland County Department of Social Services. Currently, this program is in the planning phase, however, by providing your contact information we can update you as information becomes available.
Name*

First NameLast Name
Residential Address*

Street Address

Apartment #

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Should be Empty:

Tenant Contact Information