Restricted SECURITY DEPOSIT APPLICATION

SECURITY DEPOSIT INTAKE & REFERRAL FORM
Do you live in Princeton?*

Yes, I live in Princeton.No, I do not live in Princeton
Applications for non-Princeton residents are currently closed. Please check back on the first of the month when applications will reopen.

Please click here if you are need of immediate help:

https://www.housinghelpnj.org/tenants

Thank you.

Please refer to https://www.housinginitiativesofprinceton.org/get-help for additional resources.
Today's Date

MonthDayYear
REQUESTOR INFORMATION
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Street Address
City
Zip
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)
HH member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly)
HH member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly)
HH member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly)
HH member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly)
HH member
Income Source
Amount
Frequency of payment (weekly, biweekly, monthly)
HH member

DOCUMENTATION WE WILL NEED
In order to process your application we will need the following documents:
- Photo ID for Leaseholder
- Letter on Letterhead from new landlord listing apartment address, monthly rent, potential occupancy date or signed lease
- Rent ledger from current landlord
- Proof of ALL income to the household

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
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SECURITY DEPOSIT INTAKE & REFERRAL FORM