To begin the process, please enter your name and Zip Code.
First Name
*
Middle Name
Last Name
*
Suffix
Zip
*
Do you rent?
*
Yes
No
Is your name on the rental agreement or lease?
*
Yes
No
Can you pay rent next month?
*
Yes
No
Are you behind on rent?
*
Yes
No
Do you receive any housing subsidy?
*
Yes
No
Do you have Social Security Number
*
Yes
No
Do not know
Refuse to answer
Social Security Number. (Last 4 digits only):
*
XXX-XX-
Gender
*
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming (i.e. not exclusively male or female)
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Race
White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
Do not know
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Ethnicity
*
Non-Hispanic
Hispanic
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Birthday
*
Select Month
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12 December
Select Day
01
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31
Select Year
1913
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2003
2004
2005
2006
2007
2008
Do not know
Refuse to answer
Veteran Status
*
Yes
No
Do not know
Refuse to answer
How many months behind on rent?
*
Monthly rent
*
Have you filed a declaration of COVID-19 related financial stress?
*
Yes
No
Have you received an eviction notice?
*
Yes
No
Date on the eviction notice received
*
Is your situation due to COVID?
*
Yes
No
Current monthly income:
*
Have you moved because of economic factors 2 or more times in the last 60 days
*
Yes
No
Household with dependent children 0 to 17
*
Yes
No
Household with currently pregnant woman
*
Yes
No
History of homelessness as an adult
*
Yes
No
Housing will be lost within 14 days
*
Yes
No
Housing will be lost within 21 days
*
Yes
No
Domestic violence or abuse in household
*
Yes
No
Household with a senior, 65 years or older
*
Yes
No
Household with an individual convicted of a felony
*
Yes
No
Someone in the household has a mental or physical disability and/or circumstances that affect housing
*
Yes
No
History of previous evictions
*
Yes
No
Have you been out of work for 3+ months?
*
Yes
No
Sudden and significant loss of income
*
Yes
No
Applied for shelter and spent at least one night during the prior 60 days literally homeless
*
Yes
No
Rental and/or utility arrears
*
Yes
No
Mobile Phone
*
Other Phone
Email
Address
*
Select One...
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