Rental/Mortgage Assistance

Your First Name

Your Last Name

House Number

Street Name

Zip Code

Email

Re-enter Email

Mobile Phone

Re-enter Mobile Phone

AT&T Boost Mobile Cricket Metro PCS Nextel Sprint PCS T-Mobile US Cellular Verizon Wireless Virgin Mobile Other Mobile Phone Carrier

Employed – maintained income Employed – reduced income Unemployed - Not Receiving Employent Benefit Unemployed - Receiving Employent Benefit Employment Status

Renter Homeowner Renter/Homeowner

Name of Landlord

Monthly Rent Payment

Yes No Is Rent Affordable

Good - Responsive to Issues Ok - Reasonably Responsive Poor - Not Responsive and Greedy Landlord Rating

Yes No Are You Late on Your Payment

Number of Months Late

Yes No Are You at Risk of Eviction

Yes No Do You Need Rental Assistance

Yes No Did You Apply For Payment Assistance

Rental Assistance Explanation

Name of Lender

Mortgage Balance

Monthly Mortgage Payment

Yes No Is Payment Affordable

Yes No Are You Late on Your Payment

Number of Months Late

Yes No Do You Need Payment Assistance

Yes No Did You Apply For Payment Assistance

Payment Assistance Explanation