Princeton Residents Rental Assistance

RENTAL ASSISTANCE APPLICATION
To be eligible, you must have regular income through a job or assistance such as SSI or SSD, so that you can afford your monthly rent after any back rent assistance is given.
I have regular income
I live in Princeton
Date

MonthDayYear
Date
REQUESTOR INFORMATION
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
Gender
Ethnicity

LatinoNon Latino
Race
Marital Status
* Some of the funding supporting our Rental Assistance Program requires us to collect demographic information.

HOUSEHOLD INFORMATION
List all members of your household, their relation (husband, daughter, etc.) and age.
Name
Relation
Age
Name
Relation
Age
Name
Relation
Age
Name
Relation
Age
Name
Relation
Age

CURRENT HOUSEHOLD GROSS INCOME INFORMATION
Please include income from all jobs, pension, Social Security, Disability, Child Support, NJ Unemployment, SNAP, LIHEAP of ALL household members (HH).
Income Source
Amount
Frequency of Payment (weekly, biweekly, monthly)
Household member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly):
Household Member
Income Source
Amount
Frequency of Payment (weekly, biweekly, monthly)
Household Member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly)
Household member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly)
Household member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly)
Household member

HOUSEHOLD EXPENSE INFORMATION
Not limited to, but including rent/mortgage, electric/gas, phone, internet, food, transportation, storage unit, etc. of ALL household members.
Monthly Rent
Monthly Electric/Gas/Utilities
Monthly Communication (Phone, Internet, TV)
Monthly Food
Monthly Transportation (Car, Gas, Insurance, etc.)
Other Monthly Expense (specify Expense and Amount)
Other Monthly Expense (specify Expense and Amount)
Other Monthly Expense (specify Expense and Amount)
What is your rent per month?
How much do you currently owe on your rent?
How many months in the past year have you been unable to pay your rent without assistance?
Do you currently have an eviction notice?
Do you have any pending applications for Rental Assistance?

YesNo
If yes, please list agencies here:
Are you named on the lease?

YesNo
Landlord's Name
Landlord's Phone Number
Please enter a valid phone number.
Landlord's Adress:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landlord's Email
example@example.com
How much can you contribute to your current emergency, if any?
Tell us a bit about your current situation:

ADDITIONAL INFORMATION
Name of individual who assisted in completing this application, if any:
DISCLOSURE AGREEMENT
I give permission to HOUSING INITIATIVES OF PRINCETON or its authorized representatives to disclose any information given on this intake form. I understand that my information will be used to coordinate with different service organizations including but not limited to Princeton Human Services, Princeton Senior Resource Center, Princeton Housing Authority, Princeton Community Housing, St. Vincent de Paul, HomeFront, Arm-in-Arm, Nassau Presbyterian Church, Princeton Alliance Church, Stone Hill Church, or my landlord.

I hereby give permission to disclose any of the above information as necessary to complete my request for support.
I have read this release, and I fully understand the contents, meaning, and impact of this disclosure agreement.*

I consent
Should be Empty:

RENTAL ASSISTANCE APPLICATION