Rental Assistance Interest Form
For San Bernardino County Residents Only. Must provide current proof of an eviction notice. (Not Future Eviction)
Owner ID
Do you live in San Bernardino County, CA?
*
Yes
No
What City?
*
Please Select
Adelanto
Apple Valley
Barstow
Big Bear Lake
Chino
Chino Hills
Colton
Fontana
Grand Terrace
Hesperia
Highland
Loma Linda
Montclair
Needles
Ontario
Rancho Cucamonga
Redlands
Rialto
San Bernardino
Twentynine Palms
Upland
Victorville
Yucaipa
Yucca Valley
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Gender
*
Female
Male
Other
Race/Ethnicity:
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic
LatinX
Native Hawaiian or Other Pacific Islander
White
Other
If Other Race/Ethnicity (please specify):
Do you have current proof of an eviction notice? (Not Future Eviction)
*
Yes
No
Total Amount Needed to Prevent Eviction? $
*
What type of Service are you requesting?
*
Rental Assistance (Eviction Prevention)
Move-in Assistance (Deposits and/or First Month's Rent)
How many people are in your household (including yourself)?
*
How many are children (under age 18)?
*
How many are adults (age 18+)?
*
Submit
Should be Empty: