Rental Assistance Lottery Request Form
Applicant Information
Provide accurate personal information to begin your request.
Full Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
*
Please enter a valid phone number.
Email Address:
*
example@example.com
What is your ethnicity?(Please select one or more that apply)
*
Black or African American
Hispanic or Latino/a/x
White
Other (please specify): ___________
Have you experienced any of the following?(Please check all that apply)
*
Domestic violence by an intimate partner
Sexual violence
Neither
Current Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Eligibility Screening
Answer the following questions to determine your eligibility for our guest-led experience journey.
Are you behind on rent for at least one month?
*
Please Select
Yes
No
You are not eligible for this program.
Do you have a demand letter from your landlord?
*
Please Select
Yes
No
Do you have an updated and signed lease agreement by you and your property manager?
*
Please Select
Yes
No
Is your income less than or equal to 30% of the income limit?
Please Select
Yes
No
You are not eligible for this program.
Section 3: Household Information
Number of Dependents in Your household:
*
Required Documentation Checklist (Please ensure you have all necessary documents ready for your welcoming session appointment)
ID for all adults
Birth Certificates for dependents
Lease Agreement
Demand Letter
Income Documentation (benefits statement/pay stubs)
Section 4: Enrollment Requirement
Are you willing to enroll in our Guest-Led Journey Experience?
*
Please Select
Yes
No
Enrollment in the Guest-Led Journey Experience is a required step to qualify for assistance.
You must enroll in the program to qualify
Section 5: Agreement & Consequences
Please review and agree to the program's terms to proceed.
Attestation Statement (Checklists)
I understand that I must bring all required documentation to my scheduled appointment.
I understand that if I fail to bring all documentation, I will be disqualified for 90 days.
I agree to the terms of this program.
Signature
*
Section 6: Submission Confirmation
How did you hear about this program?
*
Please Select
Website
Social Media
Referral
Other
Let us know how you found out about this program and confirm your submission.
If you selected 'Referral' or 'Other,' please provide additional details below:
*
Submit
Should be Empty: