Short-Term Rental Assistance Application

Short-Term Rental Assistance Application

Puede traducir este formulario con la bandera de idiomas en la esquina derecho
Email - *This is the only way you will receive notice of application status
example@example.com
Important: All sections must be completed in order to be considered for Rental Assistance. A completed application is not a guarantee of assistance.
Date *

Month Day Year
Date
Name *

First Name Last Name
Unit Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number

Requesting:

Eviction Prevention Move-in Assistance*
*NeighborImpact is not able to help with housing search for short-term assistance
Do you have a notice to vacate?

Yes No
72 Hour Eviction Summons
Monthly Rent Amount:
Have you been approved?

Yes No
Deposit Amount:

Household Information