EVICTION . FORECLOSURE . UTILITY ASSISTANCE
Please complete this form in its entirety! The content that you provide will be kept confidential, and will be utilized in mitigating your need for rental assistance.
By clicking the button below, I agree that all information provided in this application will be shared with non-profit partners who provide rental, and utility assistance
I agree
What do you need assistance with?
Rent
Mortgage
Utilities
Move-in Deposit
What county do you reside?
Please Select
Cherokee
Clayton
Cobb
Dekalb
Douglas
Fulton
Gwinnett
Henry
Rockdale
I don't see my county
Tenant #1 Name
First Name
Last Name
Tenant #2 Name (if applicable)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your current living situation?
Please Select
Hotel Room
On the streets
Own my house/Condo
Renting a room
Renting an apartment/house
Shelter
Transitional Housing
What date did you move in? (Month & Year)
What type of eviction are you facing?
Please Select
Apartment
Private Landlord
Pre-Foreclosure
Probate
Knowing your eviction type helps us to better understand proper protocol.
Is the lease/mortgage in your name?
Please Select
Yes
No
What is the monthly rent/mortgage payment?
Are you are Housing Choice/Section 8, or any other subsidized housing program participant?
Please Select
If yes, what program are you a participant of?
How much rent/mortgage assistance are you seeking? (Please note that agencies cannot guarantee your specific amount requested will be met)
What is your Landlord's name, Name of the Property Management Firm or Complex? (Who's name would the check be made out to)
What amount can you put toward your balance owed?
Have you been served?
Please Select
Yes
No
If yes, do you have a court date?
Please Select
Yes
No
I am
months behind. I owe $
. I have
days until I am served/have to vacate the premises.
What day has your court date been scheduled for?
-
Month
-
Day
Year
Date
Do you have a Plan B?
Please Select
Yes
No
Working on it
Maintaining shelter in today's economy has really become challenging. We want to help you maintain the stability of your shelter.
If facing foreclosure, are you interested in selling?
Please Select
Yes
No
If it makes sense
Every situation is totally different. Mitigating a resolution makes sense is our key focus.
What is your source of income? Please select all that apply
Please Select
W2 Employment
Social Security Disability
Social Security Income
Pension/Retirement
Other/No Income
Please explain other income
Are you able to pay your rent, mortgage and/or utility expenses moving forward?
Please Select
Yes
No
Do you have children under the age of 18 living in the home?
Please Select
Yes
No
Are you or anyone in your home a Veteran?
Please Select
Yes
No
Have you ever received rental assistance in the past?
Please Select
Yes
No
If so, when?
Documentation
Do you have a government issued ID?
Please Select
Have on hand
Do not have, can get
Will need help getting
Cannot get, do not exist
Do you have a government issued Social Security Card?
Please Select
Have on hand
Do not have, can get
Will need help getting
Cannot get, do not exist
Do you have a copy of your lease/deed-mortgage statement?
Please Select
Have on hand
Do not have, can get
Will need help getting
Cannot get, do not exist
Do you have proof of income (Paystubs, letter from employer, DOL Form, Social Security Award Letter)
Please Select
Have on hand
Do not have, can get
Will need help getting
Cannot get, do not exist
Do you have a Late/Eviction Notice?
Please Select
Have on hand
Do not have, can get
Will need help getting
Cannot get, do not exist
Do you have a copy of most recent utility bill?
Please Select
Have on hand
Do not have, can get
Will need help getting
Cannot get, do not exist
Have you had a recent crisis? (Medical Emergency, Loss of employment, Fire/Natural Disaster or any other type of emergency hardship)
Please Select
Yes
No
Please tell us your story about what has caused you to get behind on your rent/utilities
Schedule Call Appointment
Signature
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