Emergency Rental, Rapid Re-Housing and Utilities Assistance
Please complete as much of this form as possible for quicker response. The answers you provide will assist us in determining the best funds available for your situation.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Are you homeless?
*
Living in a shelter
Living in a hotel room
Living in my car
Living with friends
Living on the street
None of these above, I'm still living in my home
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Are you 18 years old or over?
*
Yes
No
Is your household income
*
Less than $22,000
Between $22,000 and $44,000?
Over $44,000?
Do you have a written past due notice on your rent?
*
Yes
No
Do you have a Notice to Quit where you are currently living?
*
Yes
No
Do you have an eviction notice with a court date?
*
Yes
No
If you have an eviction notice with a court date, when is your court hearing?
-
Month
-
Day
Year
Date
Do you have a written past due notice on your utilities?
*
Yes
No
Have you received any other assistance from a government fund?
*
Yes
No
Did you lose your job or receive less pay because of COVID-19?
*
Yes
No
Have you been unemployed for the last 90 days or more?
*
Yes
No
Is your situation due to being a victim of domestic violence?
*
Yes
No
Date
*
-
Month
-
Day
Year
Date
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Do we have permission to leave a message/text on the numbers provided?
*
Yes
No
Signature
*
Clear
Submit
Should be Empty: