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Emergency Rental Assistance Application
Applicant Name
*
First
Last
Mailing Address
*
Street Address
Apt #
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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:
*
High School or less, no diploma
Diploma or GED
Some College
Certification/Trade School
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Prefer Not to Answer
Are you currently working?
*
Yes
No
Domestic Violence Victim/Survivor?
*
Yes
No
Client Refused
When did DV last occur?
Within the past 3 months
3-6 months ago
6 month to 1 year ago
More than 1 year ago
Client Refused
Applied for Rent Assistance Before?
*
Yes
No
If yes, when and where?
Income and Sources
Earned income (money earned from a job)
Receiving income?
*
Yes
No
Monthly gross amount
Unemployment insurance
Receiving income?
*
Yes
No
Monthly gross amount
SSI/SDI/Disability
Receiving income?
*
Yes
No
Monthly gross amount
Temporary Assistance for Needy Families (TANF)
Receiving income?
*
Yes
No
Monthly gross amount
General Assistance
Receiving income?
*
Yes
No
Monthly gross amount
Child Support/Alimony
Receiving income?
*
Yes
No
Monthly gross amount
Other source
Receiving income?
*
Yes
No
Monthly gross amount
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
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:
Staying with family or friends
Motel/hotel
Shelter
Place not meant for human habitation
How long have you been there?
If Housed
Landlord Name
First
Last
Landlord Phone
Landlord Phone
Landlord Address
Landlord Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Accepted file types: pdf, jpg, png.
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.
Standard ERA Rules and Policies
*
Please download the
Standard ERA Rules and Policies Document
.
Print and sign the document, and then mail or email the signed Standard ERA Rules and Policies Document and all required documentation to:
City of Champaign Township
ATTN: Bailee VanAntwerp
53 E. Logan St.
Champaign, IL 61820
or
bailee.vanantwerp@champaignil.gov
Note that your application will not be processed until all required documentation is received by the Township.
Please check the box below to confirm that you have read and understand the rules and policies.
I have read and understand the Standard ERA Rules and Policies
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.
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