Rent Assistance Interest Form

Rent Assistance Contact Information

Applications for rent assistance will be opening soon. If you are behind in rent, please complete this ONE- minute interest form and we will contact you when more funds become available - on or before May 17, 2021. At that time we will send you information about the next steps you will have to complete to be considered for eligibility of rental assistance.

Rent Assistance Contact Information

Date*

Name*

First Name

Last Name

Phone Number*

Email*

Zip Code*

How many people are in your household? *

How many are children under the age of 18?*

How many months behind in rent are you? *

What is your race/ethnicity?*

What sources of income do you have (check all that apply):*

No Income Employment Unemployment Insurance Social Security, Disability, HEN, and/or TANF

Other:

Check all that apply: *

My household has experienced homelessness in the past 5 years Me or someone in my household is at risk of severe illness as per CDC (age 62 or older, or underlying health condition) None of the above