Unit Eligibility Request
Head of Household Name
*
First Name
Last Name
Last 4 digits of your Social Security number
*
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Have you given notice to move, to BOTH your landlord and CIRHA?
Yes
No
Thinking about moving soon
I am a new lease up
When are you wanting to move?
*
-
Month
-
Day
Year
NOTICE:
A move in on the date selected will not be approved as a 30-day notice was not given in a timely manner. This form is NOT a substitution for a 30 day notice. Notices are due on the 1st of the month. A copy of the notice given to the landlord is also required. Assistance ONLY starts on the 1st of the month.
Address of potential unit
Street Address
Apt #
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Name of landlord or complex
Phone number of landlord or complex
Please enter a valid phone number.
Rent
*
Base rent only, do not include amenities such as a garage or pet rent
How many bedrooms?
*
1
2
3
4
Type of home?
*
Apartment
Townhome
Duplex
House
Mobile Home
What utilities will you be responsible for?
*
Heat
Gas
Electric
Water
Sewer
Trash
Range/Microwave
Refrigerator
None
The heat is powered by:
*
Natural Gas
Bottled Gas
Electric
Electric - Heat Pump
Fuel Oil
Other
The cooking is powered by:
*
Natural Gas
Bottled Gas
Electric
Electric - Heat Pump
Fuel Oil
Other
The air conditioning is powered by:
*
Natural Gas
Bottled Gas
Electric
Electric - Heat Pump
Fuel Oil
Other
The water heater is powered by:
*
Natural Gas
Bottled Gas
Electric
Electric - Heat Pump
Fuel Oil
Other
Who is your housing coordinator?
*
Audrey Craig
Edita Ordagic
Rochelle Meister
Not sure
E-Signature
*
By signing, you understand that this form is not a substitution for a 30-day notice. You also understand that figures run for eligibility are based off of the information submitted on this form.
Clear
Please verify that you are human
*
Submit
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