Rental or/and Utility Assistance Request Form

Rental or/and Utility Assistance Request Form
What Type of Assistance Are You Requesting? *

Head of Household Information

Gender *
Ethnicity *
Race *
Address
City
State/Province
Zip/Postal
Do you rent or own your housing? *

Other Adults in Household

Adult #2: Gender *
Adult #2: Ethnicity
Adult #2: Race
First Name, Last Name, Middle Initial, Date of Birth, Social Security Number, & Ethnicity

Children in the Household

Child #1: Gender *
Child #1: Ethnicity *
Child #1: Race *
Child #2: Gender
Child #2: Ethnicity
Child #2: Race
Child #3: Gender
Child #3: Ethnicity
Child #3: Race
Child #4: Gender
Child #4: Ethnicity
Child #4: Race
First Name, Last Name, Middle Initial, Date of Birth, Social Security Number, & Ethnicity

Livelihood Questions

Have you experienced Domestic Violence? *
If yes, please check all that relate below.
Are you receiving any non-cash benefits (food stamps, WIC, Medicaid, etc)? *

Rental Assistance Needed

Are any household members CURRENTLY unemployed AND experiencing 90 or more consecutive days of unemployment? *
What best describes the status of the main breadwinner of the household? *
Do you currently have one of the following: *

Utility Assistance Needed

Are you currently working with another organization for rent OR utility assistance? *
If so, which one: