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English (US)
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Community Household Assistance Program
Must have submitted a Pre-Screening Intake Form first.
Full Name
*
First Name
Last Name
What type of assistance are you seeking?
*
Rental arrears
Mortgage arrears
Utility Assistance
Eviction Prevention
Employment/Re-Employment Assistance
Only two (2) types of assistance can be applied for. (i.e. Rental arrears and Utilities; or Mortgage and Utilities, etc.)
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please, enter your phone number
*
Please, enter an alternate phone number
*
Please enter your e-mail
*
example@example.com
Gender
*
Please Select
Male
Female
Other/Non-Conforming
Ethnicity (Check One)
*
Please Select
Hispanic
Non Hispanic
Race (Check One)
*
Please Select
African American/Black
Asian
Bi-racial
Caucasian
Hawaiian or Pacific Islander
Native American
Multi-racial
Are You Employed? (Check One)
*
Please Select
Yes
No
Are you a Veteran? (Check One)
*
Please Select
Yes
No
Are you on active duty? (Check One)
*
Please Select
Yes
No
N/A
Preferred Method of Communication? (Check One)
*
Please Select
Email
Telephone
Text Message
Enter the last four digits of your Social Security Number XXX-XX-
Number
*
Number of Individuals in the Household:
*
Number of people living in the home at the same address.
Number of children in the Household (under 18):
*
Number of children living in the home at the same address.
Please enter names, birthdates, and ages of ALL individuals living in the household.
*
Rows
Last, First Name
Date of Birth
Age
Monthly
Income Rec'd
1
2
3
4
5
6
7
8
9
10
Income received by ALL family members:
*
Earned Income/Wages
Self Employed/Home Based Business/Contract Workers
New Employment
Returned to Work
SSI
SSDI
SSA
Child Support
TANF
Alimony
Unemployment Benefits
Retirement
Other
Other: List and Explain
Proof of Residency - State issued identification, passport, military identification
*
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Proof of Residency
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of
Social Security Card(s) For head of household, minors, and individuals over the age of 18
*
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Copy of SS Card(s)
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of
Applicant must be able to provide documentation at least 30 days of loss of income during the period requested. MUST BE IMPACTED BY COVID-19 PANDEMIC!!! NO EXCEPTIONS!! (as of January 1, 2022)
*
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Proof of loss of income
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of
Please submit the first page and signature page of lease agreement or Mortgage documentation
*
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Copy of Lease or Mortgage Verification
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of
For Rental Arrears, Only - Copy of Notice to Vacate Property/Dispossessory Notice
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Copy of Notice to Vacate Premises or Dispossessory Notice
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of
Copy of Utility Bill/Georgia Power or Grady County EMC
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Utilities Past Due Notice Only.
Cancel
of
Earned Wages -Proof of Employment Wages
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Paystubs, contract pay stubs, etc.
Cancel
of
Unearned Wages -Proof of Income
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SSA/SSDI (If applicable)
Cancel
of
Unemployment Benefits -Proof of Income
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Unemployment Benefits Letter, etc. (If applicable)
Cancel
of
Three Months Bank Statement, CashApp, Zelle, Chime, Venmo, PayPal, etc. - Proof of Loss of Income
*
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Choose a file
This is mandatory and must be submitted.
Cancel
of
Consent Forms and Program Participant Agreements
Rental, mortgage, eviction prevention, and /or utilities is not guaranteed even when a person appears to be eligible during the first client screening
All information will need to be verified with appropriate documentation before any rental, mortgage, eviction prevention, and/or utility assistance is given
The information that the applicant provides is truthful, complete, and accurate.
I give permission to Community Outreach Training Center, Inc. (COTC) to share any of the above information with their partnering agencies, landlords and/or utility companies in order that COTC staff to process my application in the most efficient manner possible. COTC will not share the above information with any persons or agency, landlord or utility company representative which are not apart of COTC unless mandated to do by law. In addition, I am willing to be contacted by the identified method of contact by staff from COTC for the purposes of case management and program evaluation.
I consent to having this website store my submitted information. I understand that my application will not be submitted if all pertinent information is not submitted.
I certify that the funds will be used only for the approved purposes detailed in this application, and in accordance with the American Rescue Plan Act
I understand that I have 48 hours from the date of application submission to present all requested information or may have to reapply for assistance.
*
Yes
No
Please verify that you are human
*
Signature
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