Emergency Rental Assistance Application - City of Champaign Township

Applicant Name*

First Last

Mailing Address*

Street Address Unit # City State ZIP Code

Phone*

Email*

Date of Birth*

SSN or VISA/Immigration #:*

Do you currently or have you served in the US Military?*

Yes
No
I choose not to answer this question

Gender:*

Male
Female
Other
I choose not to answer this question

Do you identify as having a disability?*

Yes
No
I choose not to answer this question

Race/Ethnicity:*

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
I choose not to answer this question

Hispanic/Latino:*

Yes
No
I choose not to answer this question

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
I choose not to answer this question

Do you identify as a domestic violence victim or survivor?*

Yes
No
I choose not to answer this question

About how long ago did the last DV incident occur?

Within the past 3 months
3-6 months ago
6 month to 1 year ago
More than 1 year ago
I choose not to answer this question

Income (before taxes & deductions) and 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

Housing Choice Voucher, Subsidy, HUD-rental assistance, or other ongoing housing assistance*

Receiving benefit?

Yes
No

Other source*

Receiving benefit?

Yes
No

Current Employment

Click the + button on the right side of the screen to add each household member who is employed.

Family Member	Name of Current Place of Employment	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. Click the + button on the right side of the screen to add each household member.

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

Living Situation

Living Situation*

On a lease and paying rent
Secured Housing, needing deposit assistance

Property Manager/Management

First Last

Property Manager/Management Email Address

How long have you lived at your current address?

Resource/Referral Questions

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

Yes
No

Expiration Date:

Did you receive a court-ordered eviction notice?*

Yes
No

Expiration Date:

Court Date:

Do you owe on utilities? If yes, check all that are past-due at this time.

Water
Electric/gas
Sewer
Other

What short-term emergency occurred that resulted in you not being able to afford rent or pay your deposit?*

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)

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

Please list or describe what resources

Please list or describe what resources you need at this time

Upload all required documentation here.*

Please review the checklist of required documents here. All documentation listed on this checklist must be turned in with the application itself. If you are having trouble uploading the documents, you will need to either try to upload them on a different computer or save the documents as a different type of file. Files accepted are jpg, png, and pdf. The maximum file size is 100 MB.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 100 MB.

Rent Assistance Request

Assistance provided is determined by the availability of funds when the application is processed.

What is your base rent cost per month?*

How much are you requesting from Township Programming?*

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 the signed Standard ERA Rules and Policies Document and all required documentation to:
City of Champaign Township
ATTN: Emergency Assistance
53 E. Logan St.
Champaign, IL 61820

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*

Date

Phone

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