Rent Assistance Check Request
Person Requesting
*
Brenda Greer
Nathan Carter
Emily Looker
Date Submitted
*
-
Month
-
Day
Year
Date
Client Name
First Name
Last Name
CLIENT ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Verify the Following:
Client is at least 2 months past due.
Client has completed the required Budget Class.
Client has a plan for future rent payments.
Client is eligible for assistance based on known criteria.
Charity Tracker #
Landlord Name / Mailing Address
Amount Requested
Monthly Rent
Amount Behind
Rent Period Covered
Additional Notes
Submit
Should be Empty: