COVID-19 Rental/Mortgage Assistance

COVID-19 Rental/Mortgage Assistance Request Form

Head of Household Information

Veteran *
Hispanic or Latino *

Other Adult in Household

Veteran *
Hispanic or Latino *
Spouse (Significant Other) / Mother / Father / Roommate / Son / Daughter
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

Children in the Household

Hispanic or Latino *
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

Assistance Needed

Reason for Requested Assistance *Must be able to verify reason given* *
i.e. Business closed due to stay in place order, resulting in loss of income. Please provide as much information as possible.
Please provide a monetary amount.
What month are you requesting assistance for? *
Have you applied for Unemployment *
Have you filed for your 2018 or 2019 Tax Return? *
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