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Homelessness Prevention Grant


DISCLAIMER:

  1. 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.
  2. 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.
  3. Any staff member that shows up at your housing unit should present a badge prior to letting them enter your home.

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)

Service Address

Household Information

Assistance being requested (Select all that apply)

Do you have a signed lease agreement that is more than 2 months behind on rent?   

When does your lease expire?   

What was the last month you were able to pay your full amount of rent?   

What is the name of the property management company / or Landlord where your rent is paid?   

Company / Name   

Phone Number   

Mailing Address (Street, City, Area Code, State)   

What is the name of the company that you pay to heat your residence?   

Name appearing on primary utility bill   

Account number on primary utility bill   

Current amount owed to utility   

Do you have a past due notice for primary utility?   

Are you disconnected or have you received a disconnect notice?   

Are you covered by Health Insurance? *  

Are you a domestic violence victim/survivor? *  

If yes for Domestic Violence, when?   

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.

Notes and Comments

Send me a copy of my response (requires an email listed in the “Information on Household Member(s)” section above)

Be joyful in HOPE, patient in affliction, and faithful in prayerRomans 12:12