The Emergency Solutions Grant (ESG) that you are applying for requires all clients to agree to an in-home inspection to determine if the housing unit meets the ESG minimum habitability standards.
In compliance with CDC guidelines, all parties present during the time of inspection must adhere to the following COVID19 safety measures: (wearing a facial covering) (maintaining 6’ feet of social distancing) at all times while staff inspector is present.
Any staff member that shows up at your housing unit should present a badge prior to letting them enter your home.
I agree to a home inspection, and understand my responsibility to cooperate with the Covid-19 safety measures *
In what way has the Covid19 Crisis effected your financial status? (If it hasn’t, do not click a box)
Information on Household Member(s)
Prefer not to answer
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Multi-race (two or more of the above)
Hispanic, Spanish or Latino Origins
Not Hispanic, Spanish or Latino Origins
How long have you lived at this residence?
One night or less
Two to six nights
One week or more, but less than one month
One month or more, but less than 90 days
90 days or more, but less than one year
One year or longer
Rent not subsidized
Homeless with roof/sheltered
Homeless without roof/sheltered
Assistance being requested (Select all that apply)
Housing Assistance (Rent)
Are you covered by Health Insurance?
Are you a domestic violence victim/survivor?
If yes for Domestic Violence, when?
Within the past three months
Three to six months ago
From six to twelve months ago
More than a year ago
If yes for Domestic Violence, currently fleeing?
How many people are in your current household?
How many individuals provide income for this dwelling?
What is your individual monthly income? $
What is your combined monthly income? $
Income Sources for HOH (Select all that apply)
Please count all GROSS income in your house for the past 30 days. Our Specialists will further evaluate what is and isn't counted during your phone interview.
Social Security Income SSI
Social Security Disability SSD
Notes and Comments
Send me a copy of my response (requires an email listed in the “Information on Household Member(s)” section above)