721 SE 3rd, Suite D 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.
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 residnece - See a list of Rent Guarantee Program Contacts online.
Programs available at this time:
October 4, 6, 11, 18, 20, 25 & 27
9:30 am - Noon
You must attend the first session to participate
List ALL household members here. Start with yourself.
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”.
For each type of income below provide the total amount you receive each month:Earned Income / Wages $ / month* TANF / AFDC $ / month*Child Support $ / month* Unemployment $ / month* SSI / SSDI $ / month* Pension $ / month* Worker's Comp $ / month* WIC benefits $ / month* SNAP / Food Stamps $ / month* Non-cash benefits $ / month* Other $ / month*
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.