Shelby County Rent and Utility Assistance Application Form

The Works, Inc. offers free legal support for tenants facing eviction in Memphis and Shelby County. Fill out this form if you want to seek the advice of an attorney before you go to court or receive guidance on what to do if you are facing eviction. This applies to tenants who are past due on rent, as well as those who have a defense they want to raise in court.

This form is not an application for Emergency Rental Assistance. If you are seeking to apply for the THDA Rent Assistance Program, please apply at https://thda.org/help-for-renters-section-8/covidrentrelief here.

Tenants are welcome to apply for rent assistance and to request assistance from this legal support program as well.This form serves as a request for eviction assistance, provided through either legal representation or eviction counseling. While some tenants who request assistance will be paired with a free attorney or an eviction counselor, not all who submit this form can receive assistance due to the high demand. If we are unable to provide assistance at this time, we will notify you via email.

To receive legal representation, you must have an eviction court case. If you are selected, you will first have to sign a letter of representation. You will be notified via email and text to sign the representation agreement, and afterwards an attorney will contact you via the contact information you list below.

Both tenants with eviction cases and otherwise facing eviction could be eligible for eviction counseling. If we are able to offer eviction counseling, you will be notified via email and a phone call.

Para completar la solicitud en español, haga clic aquí.

First Name (Legal)*

Please provide your official, legal first name.

Last Name (Legal)*

Please provide your official, legal last name.

Date of Birth*

Applicants must be over 18 years old.

What is your preferred language?*

EnglishSpanish

Si tu idioma preferido es el español, accede a nuestra aplicación aquí.

Phone Number*

Email: Please make sure this is correct. If you do not have easy access to email, you may put not applicable.*

What is your preferred method of communication?*

Phone callEmailText

Home address: please list the address where you currently reside.

Street Address*

Street Address Line 2 (Unit)

City*

State / Province*

Postal / Zip Code*

Is your eviction filed at this address?*

Yes. I am residing at the address where I am facing eviction.No. My eviction is filed at a different address than where I currently live.I don't have a formal eviction filed with the courts.I don't know.

Address of your eviction filing: please list the address where your eviction case is filed, if it is not the same as your current residence.

Eviction Filing Street Address

Eviction Filing Address Line 2 (Unit)

Eviction Filing City

Eviction Filing State / Province

Eviction Filing Postal / Zip Code

Name of Alternative Contact 1*

First Name Last Name

Relationship to you:*

Phone Number for Alternative Contact 1*

Email address for Alternative Contact 1*

example@example.com

Name of Alternative Contact 2

First Name Last Name

Relationship to you:

Phone Number for Alternative Contact 2

Email address for Alternative Contact 2

example@example.com

Have you applied for Memphis and Shelby County's Emergency Rental Assistance program?*

YesNoI don't know

What is your application case number for Memphis and Shelby County Emergency Rental Assistance?

This is the number associated with your Neighborly application. If you applied prior to July 2021, it was emailed to you.

Have you previously received rental assistance from Memphis and Shelby County's Emergency Rental Assistance Program?*

YesNoI don't know

What is your marital status?*

SingleMarriedWidowed/divorced

What is your gender?*

MaleFemaleNon-binary/other genderPrefer not to say

What is your race?*

Do you identify as Hispanic?*

YesNo

What is the highest level of education you have completed?*

How many people live in your home?*

12-34-56+

Are there minors in your household?*

YesNoI don't know

What is your household's monthly income? Please include regular monthly payments from government assistance programs, such as TANF and SNAP.*

Dollars per month

What is your household's monthly rent? *

Dollars per month

What is your landlord's name?*

Do you rent from a real estate company or an individual?*

Real estate companyIndividualUnsure

Who is your point of contact for your landlord? If you rent from an individual, this may be the name of your landlord. If you rent from a company, this may be someone at the company.*

First Name Last Name

What is your landlord's phone number?*

What is your landlord's email address?*

example@example.com

Request for Eviction Legal Support

About You

Emergency Contact

Demographics

Landlord Information

About Your Case

Declaration

Click "Submit Form" Below & Check Your Email for Updates