North Form

Rental Assistance Program Application
GRANT REQUEST AMOUNT: $*
(should be same as stated in “Housing” section “B” on page 2 of 3)
STAFF ONLY
REF# write ref #* RECEIVED BY write your name* DATE
Date*
Applicant
Name*
First NameLast Name
Head of Household?
YesNo
California DL /State ID #
Other ID#
Current Address
City
State
Zip Code
Currently receiving Housing assistance?*
YesNo
If YES, please indicate which type of housing assistance: you receive:*
Public HousingHousing Choice Voucher/Section 8
Email*
example@example.com
Telephone

Co-Applicant
Name*
First NameLast Name
Head of Household?*
YesNo
California DL/ State ID#
Other ID#
Current Address
City
State
Zip Code
Currently receiving Housing assistance?*
YesNo
If YES, please indicate which type of housing assistance: you receive:*
Public HousingHousing Choice Voucher/Section 8
Email*
example@example.com
Telephone

FAMILY MEMBER INFORMATION
(Applicant & Co-Applicant will be required to provide 3 months of bank statements)

	LIST EACH FAMILY MEMBER LIVING IN THE HOUSEHOLD	AGE	Gender	DATE OF BIRTH MM/DD/YYYY	RELATION TO APPLICANT	Ethnicity – Select Yes if you are Hispanic origin. ETHN	Race – mark the number that identifies your Race	Employment/Unemploy‐ment/WorkersComp	Social Security/ SSDIVA Disability	TANF/WIC	Pension,Retirement, VA Benefits, Pension	Other Income‐Alimony,ChildSupport,COVID19 Payroll Program Payments
1
2
3
4
5
6

HOUSING & EMPLOYMENT INFORMATION
Name of ApartmentComplex
NA
Property Manager/Company Name
Telephone
Lease Start / EndDate
Employer Name/City
Supervisor Name
Telephone
Last DateWorked / # Hours
Please be note that we will contact your Property Manager and Employer for additional information and documentation.
By checking one of the statements below—You may be required to provide proof to document the statement.
CHECK ALL THAT APPLY
A Household Member tested positive for COVID‐19 by a source authorized by the State of California or was required to quarantinedue to exposure to someone who tested positive for COVID-19.A Household Member lost their job due to COVID-19.

	Part A: Partial Rent Paid (can be $0)	Part B: Rent Due	Date Rent Due (mm/dd/yyy)	Part A (minus) Part B = Net Rent Due
$
$
$
$
$
$
Total: $

Rental Assistance Program Application