Rent and Utility Assistance Application

Section 1: Tenant Information

First / Last name

Address

Phone number

Email address

Do you need help with completing this application

Clear choice

Yes

Reason for Applying

(Check all that apply)

Select allClear choices

I need help paying overdue rent

I need help paying overdue utility bill or turning utilities back on

Do you need language interpretation or translation services

Yes

If yes, what language do you need communications and/or forms stranslated into?

Section 2: Residence and Housing Instability Information

Housing Type

Select allClear choices

Apartment

Trailer/RV

Other:

Monthly Rent: $

Lease Expiration Date (MM/DD/YYYY)

Total Rental Debt Owed: $

Total Utility Dept Owed: $

Provide copies of the following documents

Check all that apply

Select allClear choices

Lease or written rental agreement that shows your monthly rent, your address, and is signed by you and your landlord

Letter from your landlord verifying your monthly rent and amount due

Utility bill that shows your name and address

Other documents that show your past rent payments like bank statements, check stubs, or screenshots of electronic payments

Have you received a past due rent, past due utility, eviction notice or other official notice from your landlord, the court, sheriff's office, or utility company?

Select allClear choices

Yes

Section 3: Income Eligibility

Household Member Name and Age

(i.e. First Last (Age)), seperate by ","

Provide your household income information below. Income includes wages, salaries and tips, alimony, child support, military income, Social Security, pensions, and other government benefits including unemployment payments paid to adults over 18 in your household

Where else have you applied/inquired?

What is your total household income?

Employers Name

Do you have documentation of your household income?

Clear choice

Yes

Has anyone in the household applied for or currently receive benefits or services from one of the following programs? If so, check which programs apply:

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Head Start

Low Income Home Energy Assistance Program (LIHEAP)

Supplemental Nutrition Assistance Program (SNAP)

Supplemental Security Income (SSI), for head or co-head of household

Temporary Assistance for Needy Families (TANF) or Tribal TANF, for head or co-head of household

Veterans Affairs Disability Pension, Survivor Pension, Enhanced Survivor Benefits, or Section 306 Disability Pension (not standard VA pension)

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for households with three or fewer members

Other income-based program

What led to your need for rental or utility assistance? Please provide a brief explanation of your current situation. (What unexpected event or change in circunstances has impacted your ability to pay rent or utilities?)

Verification