Emergency Rental Assistance Client Intake Form

Emergency Rental Assistance Client Intake Form
Enter your information below. When you're done, click on the sumbit button at the bottom of the form. If you're not sure about something, a staff member will be happy to help.
Self Identification
Name*

First NameMiddle NameLast NameSuffix
Maiden Name
Nickname
Date of Birth*

MonthDayYear
Date
Social Security Number*
Head of Household
Street Address and Mailing Address
Street Address*

Address

Apartment #

CityState

Zip Code
Mailing Address*

Address

Apartment #

CityState

Zip Code
County*
County*
Contact Information
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
I have read and understand the Terms and Conditions as specified on the website: www.daystarlife.org*

Emergency Rental Assistance Client Intake Form
Today's Date*

MonthDayYear
Date
What is your emergency? (Required that you select ONLY one)*
Any additional information you wish to provide? Please type below.
What is your monthly base rent? (Do not include appliance rentals/water/trash/late fees)*
How much does your late notice list as being delinquent?*
How much rental assistance are you requesting?*
How much of your own monies can you contribute?*
Number of adults in the household?*
Number of children in the household?*
Income and Expenses (Important - expenses of food, housing, and transportation are required)
Monthly Income Sources (Please be sure to include all income sources)*
Monthly Expenses*

Self Identification