Unit Eligibility Request

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 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 *
Should be Empty:

Unit Eligibility Request

NOTICE: