COVID-19 Rental/Mortgage Assistance

First Name*

Middle Initial

Last Name*

Date of Birth*

Social Security Number*

Veteran* YesNo

Hispanic or Latino* YesNo

Race* American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or Caucasian

Address*

City*

State/Province*

Zip/Postal*

Country* AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelIsle of ManItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe

Phone*

Do you rent or own?* RentOwn

Email*

First Name*

Middle Initial

Last Name*

Date of Birth*

Social Security Number*

Veteran* YesNo

Hispanic or Latino* YesNo

Race* American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or Caucasian

Relationship to Head of Household Spouse (Significant Other) / Mother / Father / Roommate / Son / Daughter

Please provide information on any additional adults in the household:* For each additional adult in the household please include: First Name, Middle Initial, Last Name, Date of Birth, Social Security Number, Ethnicity, Relationship to Head of Household

Child #1: First Name*

Middle Initial

Last Name*

Date of Birth*

Social Security Number*

Relationship to Head of Household*

Please provide information for any additional children in the household:* For each additional child in the household please include: First Name, Middle Initial, Last Name, Date of Birth, Social Security Number, Ethnicity, Relationship to Head of Household

Reason for Requested Assistance *Must be able to verify reason given* Loss of Job or IncomeReduction of HoursCaring for self or immediate family member diagnose with COVID-19Long term closure of school and or daycareOther

Please explain what the Loss of Job or Income or Reduction of Hours is due to:* i.e. Business closed due to stay in place order, resulting in loss of income. Please provide as much information as possible.

How much assistance are you requesting?* Please provide a monetary amount.

What month are you requesting assistance for?* JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Have you applied for Unemployment YesNo

If No, Please explain why you have not applied for Unemployment Benefits?

Have you filed for your 2018 or 2019 Tax Return? YesNo