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Rent Assistance
Pre-Screen Application
Date
Message
When is your rent payment due?
I have an eviction notice in hand
I'm facing eviction
Past due
Due within 10 days
Do you
Rent
Own
In which type of housing do you currently live?
Apartment
House
Duplex
Manufactured Home
Condominium
Are you living in subsidized housing, recovery housing, transitional housing, an organized group home, or does the amount of rent change if your income changes?
Yes
No
How much is your rent (not including utilities and fees)?
How many bedrooms do you have?
Do you pay utilities?
Yes
No
Which ones?
Water
Sewer
Garbage
Electric
Gas
Oil
Any utilities or fees included in your rent amount?
Yes
No
What is the gross monthly income for all adults in your household (last 30 days)
How many adults and children live in your household?
Is there anyone in the household over 58 years old?
Yes
No
Has anyone in your household experienced domestic violence in the last 12 months?
Yes
No
Is anyone in your household pregnant?
Yes
No
If yes, due date?
Are all adults on the rental agreement?
Yes
No
Do you and your roommates have separate rental agreements?
Yes
No
N/A
How much do you need help with?
Do you have money available to contribute to your rent arrears?
Yes
No
If so, how much?
Do you owe previous months?
Yes
No
Are you receiving / have received any housing assistance from CCS or any other agency in the last 12 months?
Yes
No
If yes, who provided the assistance and when did they provide it?
Why were you not able to pay rent this month?
How do you intend to pay next month's rent?
Submit
Thanks for submitting!
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