• Rent Well

    Housing Stability Services - Registration Form


  • 211 SE Byers Ave
    Pendleton, OR 97801
    541-276-1926 | 800-752-1139

     

    Serving Gilliam, Hood River, Morrow, Sherman, Umatilla, Wasco, and Wheeler counties

  • While completing this form, provide information about yourself and your situation as of TODAY.

  • Today's Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Select your county of residence*

  • This Rent Well registration form is for Oregon residents living in Gilliam, Morrow, Umatilla or Wheeler counties only. If you live outside these counties please contact an agency working in your county of residence - See a list of Rent Guarantee Program Contacts online.

  • 2026 Rent Well Program Sessions:

     
    Dates: Thursdays, October 8, 15, 22 & 29
     
    Time: 8:30 am - 12:30 pm
     
    Location: CAPECO Office - Hermiston, OR
     
    Address: 1565 North 1st St., Ste. 1, Hermiston, OR 97838
     
    Classes held in English
     
    NOTE: To participate, you must attend the first session!
     
    Register soon, before this session fills up!
     
    Need a ride to class? - All participants with or without transportation are welcome to take advantage of the public Kayak transportation bus. KAYAK - BUS SCHEDULE
  • Select one: Hermiston, Oregon
  • Select one: Pendleton, Oregon

  • Registration Information

  • Phone Number
  • Is your Mailing address the same as your Physical address?*

  • Please tell us who is in your household:

  • List ALL household members here.

    Start with yourself, then click the "+ Add More" button to add more household members to your list.

  • If you are not filling in all required fields for the questions on this form you will receive an error message.

    To be able to move through this form you will need to fill in all required fields.

    You may need to use the scroll bars to reveal all required fields above.

     

  • What is your race/ethnicity?

    *Why do we ask this? HUD asks us to collect this information to make sure that laws that protect people from being discriminated against are followed. If you are uncomfortable sharing this information, please check “prefer not to answer”.

  • Include ALL household members listed on the previous page, check all that apply: *
  • Does anyone in your household have a disability?*
  • Does this person receive social security or veterans benefits for the disability?*
  • Is anyone in your household a Veteran?*

  • Education & Employment

  • What is the highest level of education you completed?*
  • Employment Status*
  • Length of Employment Status*

  • Health & Wellbeing

  • Do you have any current or past substance use?*
  • Select all that apply*
  • Do you have any of the following health conditions? *
  • Do you have health insurance?*
  • Are you or have you ever been in a survivor of domestic violence?*
  • Are you currently fleeing a domestic violence situation?*
  • Are you on probation or parole?*
  • If you are currently homeless, have you been homeless for 12 or more months?*
  • Have you been homeless off and on for 4 or more times in the last 3 years?*

  • Current Housing Status

    Review the following statements. Check any statement that fits your current living situation.
  • I have or currently sleep in a public or private place not meant for human habitation such as:*
  • If none of the statements above fit your situation, where do you live right now?*

  • How long have you lived where you are currently living?*

  • Housing Barriers

  • You hereby certify that you have experienced the following barrier(s) to housing:*
  • Are you paying more than 1 /3 of your monthly income towards rent/mortgage?*
  • Are you currently being asked to leave your current residence and lack the resources to obtain other long-term housing?*
  • Will you have Section 8 or rental assistance when you look for your new place?*
  • Are you on any Housing Authority waitlist(s)?*

  • Income

    If you have any income, please list it below.
  • Do you receive any type of income*

  • For each type of income below provide the total amount you receive each month:
    Earned Income / Wages   *   
    TANF / AFDC *
    Child Support   *      
    Unemployment   *   
    SSI / SSDI   *   
    Pension   *   
    Worker's Comp       *   
    WIC benefits   *   
    SNAP / Food Stamps   *   
    Non-cash benefits   *   
    Other   *     

  • I hereby certify that I receive ZERO income/money from any source, including, but not limited to, income from wages, public assistance, social security, pensions, benefits, child support, alimony, self-employment, or regular gifts.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: