COVID-19 Rental/Mortgage/Utility Assistance

COVID-19 Rental/Mortgage/Utility 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

Are there minors 17 and under that live in the home? *

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. You will need entire lease or mortgage statement.
Please provide a monetary amount. You will need to get a letter from your utility company (on their letterhead) explaining that they can’t make payment arrangements.
What month are you requesting assistance for? *
Have you applied for Unemployment *
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