Emergency Rental Assistance Application - City of Champaign Township

Applicant Name*

First Last

Mailing Address*

Street Address Apt # City State ZIP Code

Phone*

Email*

Date of Birth*

MM

DD

YYYY

SSN*

VISA/Immigration #:

Are you a US Military Veteran?*

Yes
No
Client Refused
Client Doesn't Know

Gender:*

Male
Female

Do you have a disability?*

Yes
No

Race/Ethnicity:*

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Client Refused

Hispanic/Latino:*

Yes
No

Highest Level of Education:*

Are you currently working?*

Yes
No

Domestic Violence Victim/Survivor?*

Yes
No
Client Refused

When did DV last occur?

Applied for Rent Assistance Before?*

Yes
No

If yes, when and where?

Income and Sources

Total monthly income from all sources*

Non-Cash Benefits

Supplemental Nutrition Assistance Program (SNAP)*

Receiving benefit?

Yes
No

Supplemental Nutrition Program for Women, Infants, and Children (WIC)*

Receiving benefit?

Yes
No

Section 8, Public Housing, or other rental assistance*

Receiving benefit?

Yes
No

Other source*

Receiving benefit?

Yes
No

Current Employment

Family Member	Name of Current Place of Employment	Type of Work	Pay Per Hour or Yearly Gross Salary	Hours/Week

Household Composition

Household Composition*

List all person(s) who are/will be living in your household. You must use the legal name for each member of your household as it appears on their Social Security Card or Birth Certificate.

Name	SSN	Date of Birth	Relationship to Head of Household	Race	Hispanic/Latino (Y/N)	Veteran (Y/N)	Gender	Disabled? (Y/N)

Living Situation

Living Situation*

Homeless
Housed

If Homeless

Please tell us your current situation:

How long have you been there?

If Housed

Landlord Name

First Last

Landlord Phone

Landlord Address

Street Address Address Line 2 City State ZIP Code

How long have you lived at your current address?

Number of times in the past 12 months you had difficulty paying rent:

Resource/Referral Questions

Do you have a "Section 8" voucher or subsidized housing?*

Yes
No

Do you have a 5-day or 10-day notice?*

Yes
No

Expiration Date:

MM

DD

YYYY

Did you receive a court-ordered eviction notice?*

Yes
No

Expiration Date:

MM

DD

YYYY

Court Date:

MM

DD

YYYY

Do you owe past due power/utility bills?*

Yes
No

Amount Owed

What hardship caused you to not be able to pay rent this month?*

Emergency medical bill (need proof of recently paid bill)
Emergency car repair bill (need proof of recently paid bill)
Hours cut/laid off/terminated (need letter from employer)
Medical leave (need letter from employer and/or doctor)
Deposit expenses (need paid receipt/letter from landlord)
Funeral bill (need proof of recently paid bill)
School tuition (need proof of recently paid bill)
Other hardship (per manager's approval)

Please describe your hardship:*

Have you applied/are you currently receiving LIHEAP?*

Yes
No

Do you need any food resources at this time?*

Yes
No

Do you need any other resources at this time?*

Yes
No

Upload all required documentation here.*

Please refer to the checklist on the "Apply for Assistance" page to determine what is required for your application. Allowed files types: jpg, png, pdf.

Drop files here or

Rent Assistance Request

Assistance provided is determined by the availability of funds when application is processed. Monthly gross income must be 2x the amount of rent per month, unless living on a fixed income, in which case your rent must not exceed 60% of your monthly gross income.

How much is your total monthly rent obligation?*

Total amount of assistance that you are requesting:*

Maximum allowance per household is $600.

Please enter a number from 1 to 600.

If approved, payment will be made directly to the landlord.*

I understand that some funders may require that my apartment undergo a Health & Safety Inspection.
I certify that the information presented above is true and accurate.
I understand that to lie or mislead in order to obtain assistance is a fraudulent offense for which I can prosecuted.
I consent to allowing my Social Security Number to be used for the processing of my application and entrance into the Township's databases as required by the Funding agencies for reporting purposes.

Signature of Applicant:*

Date*

MM

DD

YYYY

Signature of Case Manager

(Will be handled internally)

Date

MM

DD

YYYY

Name

This field is for validation purposes and should be left unchanged.