Short Term Rental Assistance Application

Today's Date*

MonthDayYear
Date
Preferred method of contact*

EmailText message
Email *
example@example.com
Phone Number
Please enter a valid phone number.
Your Name*

First NameLast Name
What are your pronouns?

She/herHe/himThey/themI prefer not to sayOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Landlord Name*

First NameLast Name
Landlord Phone Number*
Please enter a valid phone number.
Landlord Email Address*
example@example.com

Name of applicant*

First NameLast Name
Date of birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source*

Number of ADULTS*
Ages 18 and over
Number of CHILDREN*
Ages 17 and under
Name of ADULT Household Member 2 (NOT yourself)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*
Name of ADULT Household Member 3*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*
Name of ADULT Household Member 4*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*
Name of CHILD Household Member 1*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*
Name of CHILD Household Member 2*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*
Name of CHILD Household Member 3*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*
Name of CHILD Household Member 4*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*
Name of CHILD Household Member 5*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*
Name of CHILD Household Member 6*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Monthly Income Amount:*
Income Source:*

Please choose what best fits your current situation:*

Loss of job/incomeRecent medical event resulting in loss of incomeChange in household members (someone with income left, new child in home, etc.)Recent unexpected bill (large utility bill, car repair, medical bill, etc.)Other
Is there anything else about your situation you want us to know?

Would you be willing to work with us to share your experience in receiving assistance? NeighborImpact will never release any of your personal information without your permission.*

Yes, absolutelyYes, but prefer to remain anonymousMaybe, I'd like more infoNo, thanks

If you don't want us to yet, that is okay, but we will need to contact them upon approval of services. By initialling this form, you are giving NeighborImpact permission to speak with your landlord about your situation and payment.
If NeighborImpact has permission to speak with your landlord, type initials here:*
If NeighborImpact has permission to refer to your household to the Eviction Defense Project, type initials here:
Applicant Signature*

Clear
Please verify that you are human*

Thank you for completing the NeighborImpact Housing Stabilization Short Term Rental Assistance Application!
Unfortunately, your household does not meet the current eligibility requirements for rent assistance. Please contact us if you have additional questions!

Email: rentassist@neighborimpact.org

Phone: 541-323-0222
Should be Empty: