Rental Assistance Questionnaire

Please note that qualifying for services does not guarantee funding. This form is used to help determine your eligibility to apply. This is NOT the final application form. If you meet the qualifications of the program, you are encouraged to continue on with the application process. If you do not meet the qualifications, we welcome you to reach out to our office for other resources.

Please be as thorough as possible to assist us with determining eligibility.

Name

First Name

Last Name

Email

Phone

(###)

###

####

What services are you interested in?

Rent for Household WITH children

Rent for Household withOUT Children

Do you have a child in the household under the age of 18?

Are you currently homeless?

Examples include: Staying in a shelter, fleeing domestic violence, living in a car or other area not suitable for habitation, staying in a hotel that is being paid for by a third party or non-profit.

Are you at risk of homelessness based on the description below?

Risk of homelessness includes having a 3-day notice to pay or vacate from your landlord/property management, having an eviction notice, utility shut-off notices, living in a hotel that you are paying for, or temporarily living with friends or family members

Message

Rental Assistance Questionnaire

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Programs

Five County AOG Community Action Partnership