JumpStart June 2024 Compliance Form

JumpStart Barrier Removal Assistance form
JumpStart Barrier Removal help can assist with rent payments, security deposits, mortgage payments, foreclosure help, traffic tickets, utilities, or child care.

You MUST be employed in order to receive Barrier Removal help.

You MUST be a resident of the city of Detroit.

You MUST gather all required documents FIRST.

All Documents are listed here:

https://jumpstartdet.com/barrier-removal

If you do not have the required documents, your request will be rejected.

ONLY submit ONE request per form.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMaleTransgenderGender NeutralNon-binaryPrefer Not to RespondUnknown
Race:*

Black or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Pacific IslanderWhiteSome Other RaceUnknown
Ethnicity:*
You must be a resident of Detroit to qualify for assistance. Are you currently a Detroit resident?*

YesNo
Housing Environment:*

Couch SurfingHomeless (On Street, Vehicle)Currently in ShelterLiving in uninhabitable placeOwnsRents
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
Best time to call:*

MorningAfternoonEveningWeekendsAnyText onlyUnknown
Preferred contact method:*

PhoneTextEmailIn-personAnyUnknown
Date of Birth*

MonthDayYear
Date
Which type of assistance are you requesting with this form? (only submit ONE request type per form):*

Security depositRent paymentsMortgage paymentsForeclosure assistanceAppliancesFurnitureCar repairCar insuranceChild CareUtilitiesTraffic ticketsWork clothes or work tools
Were your needs affected by the Covid 19 Pandemic?*

YesNo
Are you willing to participate in 6 months of case management services?*

YesNo
You must be employed to qualify for this program. Are you currently employed?*

YesNo
Name and Location of Employer: *
Are your rent or mortgage payments current?*

YesNo
Currently receiving Social Security or Disability benefits?*

YesNo
Number of adults ages 18-59 in household:*
Number of senior adults age 60+ in household:*
Number of children ages 0-5 in household:*
Number of children ages 6-13 in household:*
Number of children ages 14-17 in household:*
Are there any veterans in the household?*

YesNoUnknown
Are you a veteran?*

YesNoUnknown
Are you a returning citizen (state resident who was previously incarcerated)?*

YesNoUnknown
Upload the documents required for your request. Go to https://jumpstartdet.com/barrier-removal to get the checklists for each type of assistance:*

Cancelof
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JumpStart Barrier Removal Assistance form