Housing Assistance Application

Contra Costa County Residents Only

PLEASE READ: If you’ve previously applied for housing assistance or received service of any type from Catholic Charities East Bay, please contact the Catholic Charities Housing Services department instead of completing this application form. However, please note that at this time we are giving priority to those who have not previously received financial assistance.

Complete as much information as possible to avoid processing delays.
Unrelated individuals (roommates) who are listed on a lease must each file their own application for the amount of assistance each needs. Related family members in the same household only need to file a single application.
After you click submit, you will receive a confirmation email if you provided a valid email address. Your application will then be reviewed. If you don’t receive a confirmation email, you are likely already in our system and should contact our Housing Services department.
If you are not eligible for assistance, you will be notified by email, where we will let you know about other potential resources you can contact.
If you are eligible for assistance, an Intake Coordinator will contact you. You’ll need to provide the documentation listed below. Additional documentation not listed below may also be requested prior to an appointment with a Case Manager.
1. Valid Government Issued ID
2. Proof of Current Residence
3. Proof of Income
4. Documentation of Related Financial Loss

Your Contact Information

First Name:
Last Name:

Street:

City:

State:

County of Residence:

Zip Code: (5 numbers only; ex. 94607)

Email:

Mobile Phone*:
*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.

Home/Other Phone:

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?