Client Assistance Application

Rental Assistance - Landlord

To be completed and submitted by the landlord.
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that the client named above is applying for housing assistance through Eblen Charities. The funds being requested are for (please check):

Deposit fundsFirst Month's RentPast Due Rent or Mortgage

Upon signature, the landlord agrees to accept $ amount on behalf of named client to help the client avoid eviction; or to be able to take possession of the rental unit. Their monthly rental costs are $ rental amount and I agree to accept $ amount to maintain their housing for the next 30 days. The original amount was due on date
Landlord Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landlord Signature

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Date

MonthDayYear
Date

Rental Assistance - Landlord