Rental Assistance Application
The program is currently at capacity. This application will determine if you meet the requirements to be a good candidate for the program wait list. Please explore other avenues for assistance such as creating a payment plan with your landlord, or searching for other housing options within your budget, or reaching out to friends and family for assistance.
Head of Household Name:
*
Date
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of landlord / property management company
*
Is your Landlord a friend or family member?
*
Yes
No
How many members are in your household?
*
How many rooms does your current unit have?
*
What is your monthly rent?
*
How much are you behind?
*
Are you able to sustain ongoing rent on your own?
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Yes
No
Have you tried setting up a payment plan with your landlord?
*
Yes
No
How much is your total gross household income for all household members over 18 years of age? (Gross is income before taxes).
*
Have you applied for rental assistance before?
*
Yes
No
If so, when and with what agency?
*
What caused your situation?
*
Household must meet one of the following criteria AND be at or below 80% AMI OR have a HEN referral from DSHS.
*
Have a missed rent payment and currently owe all or part of a rent payment (current month or past months); OR
Has moved because of economic reasons 2 or more times during the 60 days immediately preceding the application for assistance; OR
Is living in the home of another because of economic hardship; OR
Has been notified that their right to occupy their current housing or living situation will be terminated within 21 days after the date of application for assistance; OR
Lives in a hotel/motel and the cost is not paid for by charitable organizations or by Federal, State, or local government programs for low-income individuals; OR
Lives in an Single Room Occupancy (SRO) or efficiency apartment unit in which there reside more than 2 persons or lives in a larger housing unit in which there reside more than one person per room; OR
Is exiting a publicly funded institution or system of care.
A. Household Income (check one that applies to the household). AMI is Area Median Income.
*
No Income
Income at or below 30% AMI
Income between 30% and 80% AMI
Family Size
1
2
3
4
5
6
7
8
30% of AMI
$19,500
$22,250
$28,820
$31,200
$36,580
$41,960
$47,340
$52,720
80% of AMI
$51,950
$59,350
$66,750
$74,150
$80,100
$86,050
$91,950
$97,900
B. Risk of Homelessness Factors (Check all that apply to any adult household member.)
*
Experienced homelessness in past five years.
Household member has a severe or disabling health condition, including physical, developmental, mental, or emotional impairment. This includes impairment caused by trauma, abuse, post-traumatic stress disorder, or brain injury. A person with HIV or AIDS is considered disabled.
Has a scheduled court date for eviction.
Eviction history within the past five years.
Owes more than three months of rental arrears, including current month.
History of housing disruption due to a household member’s race, ethnicity, gender identity, sexual orientation, or religion.
Social network is financially and/or emotionally strained; friends and family are also struggling financially and do not have resources to share, household has “burned bridges” with friends and family.
If you do not get this assistance, will you be homeless? select the checkbox if yes.
C. Additional Risk Factors for Young Adults (18 to 24 years old.) (Check all that apply to any adult household member.)
Person is pregnant or parenting.
Person is or has been a recipient of foster care, adoption, mental health care, drug or alcohol treatment, or has been involved in court systems.
5. Additional Notes
Forms that you will be required to supply for assistance include but are not limited to:
Copy of W-9 from Landlord
Lease agreement or equivalent
ID from Landlord
Attestation of being at-risk of homelessness (behind on rent)
Verification of income (pay stub or proof of benefits)
Rental Assistance Application
Submit
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