Rental Assistance Intake Application
Type of Assistance Needed:
Rental
Utilities
Rental & Utilities
Applicant Information
Name
Prefix
First Name
Middle Name
Last Name
Head of House
Yes
No
Social Security# Head of Household Only
Date of Birth
-
Month
-
Day
Year
Date
Address for Mailing
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other
With Friends
With Family
Place not meant for human habitation (Parks, under bridges, in car)
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email Address
Income Information
Income Type:
Earned Wage
SSI/ SSA
Child Support
Other
Total Monthly Income $ of all household members
Were you financially affected by COVID 19
Yes
No
(If yes, Please indicate why)
Loss Wage
Job closed down
Are you certified disable?
Yes
No
Are you a Veteran?
Yes
No
How many dependents do you have?
Rent Information
Monthly Rent $
What your rent include(s) (heat, etc)
Declaration
I, the applicant, agree with the following statements
“I have completed this information to the best of my knowledge. I agree to provide Heartland Coalition for the Homeless with all documents needed to assess my case for rental assistance.
Date
-
Month
-
Day
Year
Date
Signature of Applicant
Clear
Submit
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