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 Housing Job Loss/Reduced Wages
Personal Sickness Loss of Childcare, Resulting in Inability to Work
Which type of assistance do you need? (check all that apply)
Back Rent 1st Month's Rent
How much do you owe? (whole number only)
How many months do you owe? (whole number only)
Even with the eviction moratorium in place, is your landlord threatening you with eviction or asking you to leave?
Have you moved two or more times in the past 60-days because of job loss, loss of income, or other financial reasons?
Is anyone in your household currently pregnant?
Does your family have an open case with Child Protective Services?
Have you been arrested or incarcerated in the last year?