Rental Assistance Interest Form

Rental Assistance Interest Form

For San Bernardino County Residents Only. Must provide current proof of an eviction notice. (Not Future Eviction)
Owner ID
Do you live in San Bernardino County, CA?*

YesNo
What City?*
Name*

First NameMiddle NameLast Name
Phone Number*
E-mail*
example@example.com
Gender*

FemaleMaleOther
Race/Ethnicity:*

American Indian or Alaska NativeAsianBlack or African AmericanHispanicLatinXNative Hawaiian or Other Pacific IslanderWhiteOther
If Other Race/Ethnicity (please specify):
Do you have current proof of an eviction notice? (Not Future Eviction)*

YesNo
Total Amount Needed to Prevent Eviction? $*
What type of Service are you requesting?*

Rental Assistance (Eviction Prevention)Move-in Assistance (Deposits and/or First Month's Rent)
How many people are in your household (including yourself)?*
How many are children (under age 18)?*
How many are adults (age 18+)?*
Should be Empty: