Rental Assistance Application

1 Personal Information

Confidentiality Notice

All information provided in this application is strictly confidential and will be used solely for the purpose of evaluating your eligibility for rental assistance. Your personal data, including identification documents and financial information, will be securely protected in accordance with applicable privacy laws. We do not share your information with unauthorized third parties.

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Social Security Number *

Your SSN is required for identity verification and will be kept secure.

Government-Issued ID Upload

Please upload clear photos of the front and back of your Driver's License or State ID card.

Front of ID *

Click to upload front

Back of ID *

Click to upload back

Accepted formats: JPG, PNG, PDF. Max file size: 5MB each.

2 Housing Details

Current Address *

City *

State *

ZIP *

Monthly Rent Amount *

Total Amount Requested

Optional - include past due rent and any fees

Landlord/Property Manager Name *

Have you received an eviction notice?

Yes No

3 Financial Information

Employment Status *

Annual Household Income

Optional - helps us determine eligibility

Bank Name *

Important: Fintech banks (such as Chime, Cash App, Venmo, PayPal) and prepaid debit cards are not eligible for rental assistance payments. Please provide a traditional bank account.

Sources of Income (select all that apply)

Wages/Salary Unemployment Benefits Social Security Disability Child Support Other

Reason for Needing Assistance *

Additional Details About Your Situation

4 Review & Submit

Application Summary

Confidentiality Notice

All information provided in this application is strictly confidential and will be used solely for the purpose of evaluating your eligibility for rental assistance. Your personal information, including but not limited to your Social Security Number, financial details, and identification documents, will be securely stored and protected in accordance with applicable privacy laws and regulations. We do not share, sell, or distribute your information to third parties except as required by law or necessary to process your application. By submitting this application, you acknowledge and consent to the collection and use of your information for rental assistance purposes only.

I certify that all information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in denial of assistance or repayment of funds. * I authorize the rental assistance program to verify my income, employment, and housing information as needed to process this application. * I have read and agree to the Privacy Policy and Terms of Service. *

Digital Signature (Type your full legal name) *

Date

Rental Assistance Application

1 Personal Information

Confidentiality Notice

Government-Issued ID Upload

2 Housing Details

3 Financial Information

4 Review & Submit

Application Summary

Confidentiality Notice

Application Submitted!

What's Next?