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Applicant Name
*
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Mailing Address
*
Street Address
Unit #
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ZIP Code
Phone
*
Email
*
Date of Birth
*
Month
Day
Year
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
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
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
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:
Month
Day
Year
Did you receive a court-ordered eviction notice?
*
Yes
No
Expiration Date:
Month
Day
Year
Court Date:
Month
Day
Year
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.
Identification and Social Security Numbers/Immigration Proof for Household
*
Drop files here or
Select files
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
Current Lease OR New Lease (must be approved for housing already in this case)
*
Drop files here or
Select files
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
Current Payment Ledger from Landlord (shows all charges and payments made on a rental account)
*
Drop files here or
Select files
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
5/10-Day Landlord’s Notice or Court-Ordered Eviction
Drop files here or
Select files
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
Proof of Income
*
Drop files here or
Select files
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
Proof of Hardship
*
Drop files here or
Select files
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
Standard ERA Rules and Policies Document:
*
Please download the
Standard ERA Rules and Policies Document
. Print and sign the document, and then upload the signed document.
Drop files here or
Select files
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
Other documentation, If applicable
Drop files here or
Select files
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?
*
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:
*
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Date
*
Month
Day
Year
Phone
This field is for validation purposes and should be left unchanged.
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