Homelessness Prevention Grant

• Do you have a signed lease agreement that is more than 2 months behind on rent?    Yes No

• 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?    Yes No

• Are you disconnected or have you received a disconnect notice?    Yes No

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?    Yes No