City of St. Louis Impacted Tenants Fund Application

Name*

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

I am applying for aid due to:*

Building or unit condemnation (on or after 1/1/2025)Natural disaster (on or after 5/16/2025)

Event

Date of Event

MonthDayYear

Date Application Submitted*

MonthDayYear

Address on Lease*

Street Address

Apartment/Unit Number

CityState

Zip Code

Number of Bedrooms in Unit

Lease Term Starting Date

MonthDayYear

Lease Term Ending Date

MonthDayYear

Occupancy Status*

I no longer occupy the apartment or house.I currently reside in the unit, but it has been deemed uninhabitable.

Landlord/Property Manager Name

First NameLast Name

Landlord/Property Manager Email Address

example@example.com

Landlord/Property Manager Phone Number

Please enter a valid phone number.

Landlord/Property Manager Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Property Owner Name

First NameLast Name

Property Owner Email Address

example@example.com

Property Owner Phone Number

Please enter a valid phone number.

Property Owner Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Are you (the lease holder) currently employed?*

YesNo

Household/Family Annual Income

Household/Family Monthly Income

What are the sources of income for the household/family? (Please select all that apply)

Other Source of Income

Total Number of People in Your Family/Household*

Number of Household Members above the age of 18*

What are the ages of the Household Members above the age of 18?*

Number of Household Members under the age of 18*

Ethnicity

Hispanic or LatinoNot Hispanic or Latino

Race (Please select all that apply)

Other Race

Have you found another place to live?

Yes, I have signed or am preparing to sign a new lease for permanent housing.No, I am looking for housing.

Is your new residence in the City of St. Louis?

YesNoNot applicable

I understand that pursuant to applicable law, eligible tenants receive financial assistance through the Impacted Tenants' Fund on a first-come-first-serve-basis, subject to funding availability. The City of St. Louis, in administering the Impacted Tenants' fund, does not discriminate against any individual or group on the basis of race, color, ethnicity, national origin, religion, age, gender, gender identity or expression, sexual orientation, marital status, disability or any other characteristic protected by applicable laws and regulations.

To be eligible, applicant must be able to provide both of the following documents:

Valid, signed lease agreement for the impacted unit that was in effect during the qualifying event period. The lease must cover the qualifying event date to verify occupancy at the time of impact.
Valid Photo ID, Passport, Driver’s License, or other Municipal/State Identification

In addition, applicant must provide one of the following documents with the name of the applicant and the address of the impacted unit:

Utility bill
Official Government-Issued Mail (Unemployment letter, social security letter, food/cash assistance award letter, etc.) dated within the last 90 days
Voter Registration Card
Current Bank Statement

Document Upload: Valid, Signed Lease Agreement*

Document Upload: Valid Photo ID, Driver's License, Passport, or other Municipal/State Identification*

Document Upload: Utility Bill, Official Government-Issued Mail, Voter Registration Card, or Bank Statement*

By signing below, I understand that providing false, misleading, or intentionally incomplete information on this form constitutes fraud and I may be subject to civil or criminal penalties under 18 U.S.C. 287, 1001, and 31 U.S.C. 3729, as well as Missouri state law, including but not limited to RSMo §§ 575.040 and 575.060.

Applicant's Name*

Applicant's Signature

Today's Date*

MonthDayYear

City of St. Louis Impacted Tenants Fund Application

Applicant Information

Qualifying Event

Date of Application

Impacted Address

Attestation of Non-Occupancy

Landlord/Property Manager Information

Property Owner Information (if different from Landlord/Property Manager)

Income and Household Information (required information)

Voluntary Information for Reporting Purposes

Submission of Documents