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

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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