Rental Assistance Program Application Form
Applicant Information
Name
Prefix
First Name
Middle Name
Last Name
Email
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address for Mailing
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is residential address different from mailing address?
Yes
No
Do you smoke?
Yes
No
Do you have a pet?
Yes
No
Have you ever been convicted of a crime?
Yes
No
Race?
White
Black
Asian
Hispanic
Gender?
Male
Female
Household & Residency Information
People living with you
Address(es) you have lived for the last 1 year
Rent Information
Monthly Rent $
What your rent include(s) (heat, etc)
Is the bill/invoice in your name?
Yes
No
Can you provide documentation of bill(s),invoice(s),lease agreement and proof of income?
Yes
No
Do you or your spouse work?
Yes
No
Please list all current income source(s)
Have you experienced any recent financial hardships or loss of income?
Yes
No
Do you have an outstanding rental debts or eviction notices?
Yes
No
Are you receiving any other forms of government assistance?
Yes
No
Do you have any disabilities or health conditions that affect your housing situation?
Yes
No
What amount of assistance are you requesting?
How do you want to receive your rental assistance payment
Direct Deposit
Ach (Automated Clearing House)
Declaration
I, the applicant, agree with the following statements
I declare this is my application form and I fill it out as the best of my knowledge.
All the information I write here to get Rental Assistance Program.
Date
-
Month
-
Day
Year
Date
Signature of Applicant
Submit
Submit
Should be Empty: