Household Assistance Program

1
We are currently only able to serve those whose household income falls under the following income thresholds. If you answer no to the following question please understand that you are currently not eligible for this program.
2
Does your household income fall under the income thresholds noted in the previous slide?* This field is required.
YESNO
3
Since March 3, 2021, have you received assistance, received a commitment for assistance, or are you waiting on assistance from any other source for the requested mortgage/rent/utility assistance?* This field is required.
YESNO
4
If yes, please explain and be aware that you are not eligible to receive duplicate funding under this program.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
5
Requested Assistance* This field is required.Please check all that apply.
Utilities
Rent
Mortgage
Property Taxes (Incurred in 2020 and 2021 ONLY)
6
Applicant's Name* This field is required.
First Name
Last Name
7
Applicant's Phone Number* This field is required.Please fill in a phone number that would allow us to contact you and leave a voicemail if needed.
8
Co-Applicant's Name
First Name
Last Name
9
Co-Applicant's Phone NumberPlease fill in a phone number that would allow us to contact you and leave a voicemail if needed.
10
Residence Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
E-mailYou will have an option on the next slide to select your preferred contact method.
example@example.com
12
Preference to be notified by:* This field is required.
Phone
Email
Phone or Email
13
Please complete the following for ALL household members residing in the residence:* This field is required.Scroll over to the right to answer all 5 questions for each individual (Name, Age, Relationship, Race, Hispanic).
Name (First/Last)
Age
Relationship
Race
Hispanic
1
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Yes
No
2
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Yes
No
3
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Yes
No
4
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Yes
No
5
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Yes
No
6
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Yes
No
7
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Yes
No
8
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Yes
No
1
2
3
4
5
6
7
8
Name (First/Last)
Age
Relationship
Race
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Hispanic
Yes
No
Name (First/Last)
Age
Relationship
Race
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Hispanic
Yes
No
Name (First/Last)
Age
Relationship
Race
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Hispanic
Yes
No
Name (First/Last)
Age
Relationship
Race
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Hispanic
Yes
No
Name (First/Last)
Age
Relationship
Race
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Hispanic
Yes
No
Name (First/Last)
Age
Relationship
Race
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Hispanic
Yes
No
Name (First/Last)
Age
Relationship
Race
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Hispanic
Yes
No
Name (First/Last)
Age
Relationship
Race
White
Black/African American
American Indian or Native Alaskan
Asian
Native Hawaiian/Other Pacific Islander
Hispanic
Yes
No
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14
Applicant's Employer (Current)
Name
Phone Number
Street Address
Years Employed
Position
These fields have been left blank because I am not employed.
If you are unemployed, use this dropdown to indicate such.
15
*Applicant* Since March 3, 2021, have you experienced a reduction in income or an increase in expenses due to the COVID-19 pandemic?* This field is required.
YESNO
16
Co-Applicant's Employer (Current)
Name
Phone Number
Street Address
Years Employed
Position
These fields have been left blank because I am not employed.
If you are unemployed, use this dropdown to indicate such.
17
*Co-Applicant* Since March 3, 2021, have you experienced a reduction in income or an increase in expenses due to the COVID-19 pandemic?
YESNO
18
Please indicate an amount and if you are paid weekly (W), bi-weekly (BW), bi-monthly (BM), monthly (M), or annually (A). EXAMPLE: $250BW* This field is required.If you are claiming to have not received income, enter '0' in the 'Totals' columns to continue.
Applicant
Co-Applicant
Other Members Age 18+
Gross Salary (before deductions)
Overtime, Tips, Bonuses, etc.
Social Security
Disability
Pensions, Veterans Benefits, etc.
Unemployment/Workers Comp.
Alimony, Child Support
Business Net Income
Rental/Real Estate Income
Welfare Payments (TANF, Aid to Families with Dependent Children, etc.)
Other
TOTALS
Gross Salary (before deductions)
Overtime, Tips, Bonuses, etc.
Social Security
Disability
Pensions, Veterans Benefits, etc.
Unemployment/Workers Comp.
Alimony, Child Support
Business Net Income
Rental/Real Estate Income
Welfare Payments (TANF, Aid to Families with Dependent Children, etc.)
Other
TOTALS
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
Applicant
Co-Applicant
Other Members Age 18+
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19
In the prior question, are you claiming to have zero income?* This field is required.
YESNO
20
To complete the zero income verification you must check off all of the boxes below. If you are unable to check off a box, please go back to the household income question and complete the portions where you received income.* This field is required.I HEREBY CERTIFY THAT I DO NOT RECEIVE INCOME FROM ANY OF THE FOLLOWING SOURCES:
Wages from any type of employment (including commission and fees).
Income from the operation of a business. (Self-employment - Avon, MaryKay, etc.)
Rental income from real or personal property.
Interest or dividends from assets.
Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits.
Unemployment.
Public Assistance (MN Family Investment Program, General Assistance, MN Supplemental Assistance).
Alimony or Child Support
Educational grants and/or scholarships or Veteran Benefits available for subsistence after deducting expenses for tuition, fees, and books.
Regular monthly cash contributions from outside source.
And that I have no income of any kind whatsoever at this point in time and do not anticipate income from any source within the next twelve months.
21
Zero Income Verification Signature* This field is required.Please sign below to attest that the prior information is true and complete to the best of your knowledge.
Clear
22
Are you applying for rent/mortgage assistance?* This field is required.
YESNO
23
Are rent/mortgage payments current?* This field is required.
YESNO
24
RENT/MORTGAGE PAYMENTS* This field is required.
Name/Address of Rental Owner or Mortgage Holder
Current Balance Due
Lease/Mortgage Start Date
Lease/Mortgage End Date
Rent
Mortgage
Rent
Mortgage
Name/Address of Rental Owner or Mortgage Holder
Current Balance Due
Lease/Mortgage Start Date
Lease/Mortgage End Date
Name/Address of Rental Owner or Mortgage Holder
Current Balance Due
Lease/Mortgage Start Date
Lease/Mortgage End Date
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25
Are you a:* This field is required.
RenterOwner
26
Tenant Information* This field is required.
Tenant Name
Tenant Address
Tenant Phone Number
Monthly Rental Amount
27
Landlord Information* This field is required.
Business Name
Contact Name
Address
Phone Number
28
I, the above name applicant, hereby give the City of Bay City permission to communicate with my current landlord or property manager for the purpose of discussing all of the facts and circumstances of my current tenancy.
Clear
29
Applicant* This field is required.Fill out the sections that apply to the APPLICANT.
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
Checking
Savings
Money Market
401(k) Retirement
Stocks, Bonds, Mutual Funds
Whole Life Insurance
Other Accounts
Other Property Owned
TOTALS
Checking
Savings
Money Market
401(k) Retirement
Stocks, Bonds, Mutual Funds
Whole Life Insurance
Other Accounts
Other Property Owned
TOTALS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
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30
Co-ApplicantFill out the sections that apply to the CO-APPLICANT.
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
Checking
Savings
Money Market
401(k) Retirement
Stocks, Bonds, Mutual Funds
Whole Life Insurance
Other Accounts
Other Property Owned
TOTALS
Checking
Savings
Money Market
401(k) Retirement
Stocks, Bonds, Mutual Funds
Whole Life Insurance
Other Accounts
Other Property Owned
TOTALS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
CASH VALUE
INTEREST/DIVIDENDS EARNED ON THE ASSETS
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31
Copy of valid identification card or driver's license for every household member 18 years and older.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
32
Paystubs showing employment status on or before March 3, 2021 or a statement from employer.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
33
2020 or most recent tax returns. If filing separately, copies for all members.IRS Form 1040 should be submitted, W2's may be submitted on the next question.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
34
Documentation of all income for all household members. For example, unemployment, social security, disability, pension, alimony, child support, etc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
35
Bank statements (check, savings, money market, annuities, or other investment accounts) for Applicant, Co-Applicant, and all other adult members in the household.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
36
Statement from mortgage company with amount due and monthly breakdown.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
37
Unpaid Property Tax BillsIncurred in the years 2020 and 2021 ONLY.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
38
Copies of past due utility invoices.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
39
Monetary Determination Letter (unemployment) (if applicable).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
40
**WARNING! Failure to provide all required documentation will delay assistance and may result in the denial of assistance.
41
Penalty for False or Fraudulent Statement:

US. C. Title 18, Sec. 1001, provides: “whoever, in any matter, within the jurisdiction of any department or agency of the United States knowingly falsifies… or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.”

Data Privacy Act: The information being collected is considered private and will not be available to the public. This information will be used only to determine eligibility for the Household Assistance Program.

Failure to provide the requested information may jeopardize the application for rent/mortgage/utility assistance.
42
You MUST check all boxes in order for your application to be considered complete.* This field is required.
I/We understand that verification of the information provided above may be obtained from any source.
I/We understand, if I/we provide false information or fail to disclose full information as to any material fact/s, that this application may be rejected, may be terminated, and that I/we may be liable in a civil action or other legal remedy at the option of the City of Bay City.
I/We fully understand that it is a federal crime if I/we knowingly make any false statements for the purpose of obtaining this financial assistance, and that it is punishable by fine or imprisonment, or both.
I/We certify that all information in this application is true and complete to the best of my/our knowledge and belief.
I/We certify that I/We occupy the address above.
43
I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, including information provided about the citizenship or alien status for each household member applying for benefits.
44
I also certify that:* This field is required.You must check all boxes in order for your application to be considered complete.
I understand the questions and statements on this application.
I understand the penalties for giving false information.
I understand that failure to report or verify any listed requirement may deny my application.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
45
SIGNED AND ATTESTED AS TRUE, as of the date set forth below:* This field is required.Applicant Signature
Clear
46
Applicant Full Name* This field is required.
First Name
Last Name
47
Date* This field is required.
Date
Year
Month
Day
48
SIGNED AND ATTESTED AS TRUE, as of the date set forth below:Co-Applicant Signature
Clear
49
Co-Applicant Full Name
First Name
Last Name
50
Date
Date
Year
Month
Day
51
You are currently not eligible to receive assistance from the Household Assistance Program. If you need to change your answer, simply click 'previous' and it will take you back to your most recent question.
52
You are about to submit this application. Once submitted you will not be able to make any changes. If you need to change something now, please click 'previous' to go back and fix the answer that needs addressing.
Should be Empty: