Emergency Rental, Rapid Re-Housing and Utilities Assistance

Date *

Date

Name *

First Name Last Name

Date of Birth

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?

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

Transitional Living Program (TINY HOMES)

Tenant Expectations

I will be respectful of staff, self, peers and community residents.
I will remain drug and alcohol free at all times while participating in the program, services will be provided for issues with drugs or alcohol.
I will participate in a life skills group or other services when appropriate.
Participate in job skills training until I secure employment.
I agree to participate in move-in, weekly and pre-move out room inspections with my assigned or other Pivot staff
I will focus on making progress on my goals to become self-sufficient.
I will meet weekly with my assigned Pivot staff member.
I will pay rent per the identified fee schedule.
I will have contact (by text, phone, email, or face to face) with Pivot staff according to the sliding scale
I will go to wellness coaching sessions twice a month.
Visitors allowed only upon prior approval and in line with the visitor policy.
Planned overnight absences from property must be reported to Pivot staff.
Residence is forfeited after 7 days without contact; property will be held for 30 days after which participant forfeits rights to the property.

Are you interested in the Transitional Living Program (Tiny Homes)? *

Yes, I have read the Tenant Expectations and am interested in the Transitional Living Program. No

Are you married? *

Yes No

Do you own a pet? *

Yes No

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

Date *

Date

Signature *

Clear