*Check this box if you consent to receiving text messages from Catholic Charities East Bay regarding questions or information about your application for housing assistance. This consent is optional.
What are the best times to call you (Monday-Friday)? (check all that apply)
9am-11am
11am-1pm
1pm-3pm
3pm-5pm
Other Information about You
Date of Birth (please use this format MM/DD/YYYY):
Preferred Language:
Other Preferred Language:
How did you hear about us?
What is your monthly household income from all sources, e.g. wages, EDD, CalWorks, etc? (numbers only)
Did you received a 2021 Stimulus check?
How many of the following age groups, including yourself, live in your household? (numbers only)
Seniors age 55+?
Adults age 25-54?
Young adults age 18-24?
Children age 0-17?
Do you have custody of the children indicated above?
Information about Your Needs
Check this box and complete the next question if your request for assistance is related to the coronavirus/COVID-19.
How were you affected by coronavirus/COVID-19? (check all that apply)
Loss of Childcare, Resulting in Inability to Work
Loss of Housing
Job Loss/Reduced Wages
Personal Sickness
Do you have documentation to show your COVID-related housing crisis?
If your housing crisis is not related to COVID-19, please briefly explain your circumstances: (255 characters max)
Which type of assistance do you need? (check all that apply)
Back Rent
1st Month's Rent
Deposit
Mortgage
How much do you owe? (whole number only)
How many months do you owe? (whole number only)
Are you working with another agency for housing assistance?
If working with another agency, what is the name of the agency and your case worker?
Information about Your Landlord and Lease
Landlord Name:
Landlord Email:
Landlord Phone:
Are you related to your landlord?
Do you have a current lease agreement?
Do you have a payment plan with your landlord?
Even with the eviction moratorium in place, is your landlord threatening you with eviction or asking you to leave?
By clicking Submit, I acknowledge and understand that I am not guaranteed financial assistance from the Program as a result of this application.