City of Toledo Emergency Renter Assistance Fund (ERAF)
Application Form
Applicant First Name (Head of Household)
Applicant Middle Initial
Applicant Last Name
Application Date of Birth
-
Month
-
Day
Year
Date
Co-Applicant First Name (If applicable)
Co-Applicant Middle Initial (If applicable)
Co-Applicant Last Name (If applicable)
Co-Applicant Date of Birth (If applicable)
-
Month
-
Day
Year
Date
Name of other people in household
Name 1
First Name
Last Name
Name 1 Relationship
Name 1 Date of Birth
-
Month
-
Day
Year
Date
Name 2
First Name
Last Name
Name 2 Relationship
Name 2 Date of Birth
-
Month
-
Day
Year
Date
Name 3
First Name
Last Name
Name 3 Relationship
Name 3 Date of Birth
-
Month
-
Day
Year
Date
Name 4
First Name
Last Name
Name 4 Relationship
Name 4 Date of Birth
-
Month
-
Day
Year
Date
Name 5
First Name
Last Name
Name 5 Relationship
Name 5 Date of Birth
-
Month
-
Day
Year
Date
Other Names, Relationships & Date of Birth
Has anyone else living in this household received assistance from this program?
Yes
No
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Number of children/dependents living with you:
None
1
2
3
4
5
6
7+
Name of school any school-aged children living with you attend:
Are you Pregnant?
Yes
No
Pregnant - Explain the nature of this condition.
Are you Disabled?
Yes
No
Disabled - Explain the nature of this condition.
Are you Frail?
Yes
No
Frail - Explain the nature of this condition.
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Demographics
Gender:
Male
Female
Transgender
Other
Race:
African American/Black
Asian
Bi-racial
Caucasian/White
Hawaiian/Pacific Islander
Multi-racial
American Indian/Alaskan Native
Other
Ethnicity:
Hispanic
Non-Hispanic
Primary Language:
English
Spanish
Polish
Chinese
Arabic
Other
Highest Grade Completed:
No High School Diploma
GED
High School Diploma
Some College
AA Degree
Bachelor’s Degree
Master’s Degree
Doctoral Degree
Currently Enrolled in School/Training?
Yes
No
Currently Employed?
Yes
No
For Past 12 Months, Number of Months Worked?
Criminal Convictions:
Misdemeanor
Felony
No Convictions
Marital Status:
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Military Status:
Active Duty
Veteran
Spouse of Active Duty
Spouse of Veteran
Never Served
Veteran Benefit Status:
Currently receiving
Currently not receiving
Never received
Health Insurance:
Private Insurance through an Employer
Government Insurance Program
Private Insurance not through an Employer
No Insurance
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Monthly Household Income
Employment Status:
Please list last date of employment:
Are you unemployed due to COVID 19?
Yes
No
Have you experienced a recent loss in wages or hours due to COVID-19?
Yes
No
Applicant must attach unemployment claim information from ODJFS, and/or paystubs, bank statements and/or letter from employer to prove loss of employment/income due to COVID-19.
Browse Files
Cancel
of
If unemployed: Are you physically/emotionally able to work?
Yes
No
If unemployed: Have you been looking for work?
Yes
No
If unemployed: Are you involved in a job training program?
Yes
No
Does anyone else in your household work?
Yes
No
Please list income received by ALL family members: (All sources of income includes earnings from full-time, part-time, seasonal jobs, cash assistance payments, SSI/SSA, pensions, child support, alimony, unemployment, foster care payments, adoption payments, any income received on behalf of children, etc.)
Type of Income
Part time
Full time
Name of Person Receiving Income
First Name
Last Name
Name of Agency/Company
Contact Number of Agency/Company
-
Area Code
Phone Number
Gross Monthly Income
Type of Income
Part time
Full time
Name of Person Receiving Income
First Name
Last Name
Name of Agency/Company
Contact Number of Agency/Company
-
Area Code
Phone Number
Gross Monthly Income
Type of Income
Part time
Full time
Name of Person Receiving Income
First Name
Last Name
Name of Agency/Company
Contact Number of Agency/Company
-
Area Code
Phone Number
Gross Monthly Income
Additional Income
Type of Benefit - TANF
Yes
No
Name of Person Receiving Benefit
First Name
Last Name
Gross Monthly Income
Type of Benefit - Social Security
Yes
No
Name of Person Receiving Benefit
First Name
Last Name
Gross Monthly Income
Type of Benefit - Disability/Workers Compensation
Yes
No
Name of Person Receiving Benefit
First Name
Last Name
Gross Monthly Income
Type of Benefit - Child Support
Yes
No
Name of Person Receiving Benefit
First Name
Last Name
Gross Monthly Income
Type of Benefit - Unemployment
Yes
No
Name of Person Receiving Benefit
First Name
Last Name
Gross Monthly Income
Type of Benefit - SNAP Benefit
Yes
No
Name of Person Receiving Benefit
First Name
Last Name
Gross Monthly Income
Type of Benefit - Cares Act Stimulus Payment
Yes
No
Name of Person Receiving Benefit
First Name
Last Name
Gross Monthly Income
Type of Benefit - Other
Yes
No
Explain the Other Type of Benefit
Name of Person Receiving Benefit
First Name
Last Name
Gross Monthly Income
Total Household Monthly Income (Wages And Additional Income):
*
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Housing Status
Are you able to pay your rent on time most months?
Yes
No
Are you facing eviction due to late or missing payments as a result of COVID-19?
Yes
No
If yes, what is the amount of arrearage owed?
Are you currently enrolled in a rental assistance program?
Yes
No
If yes, what program:
Are you currently enrolled in the Section 8 program?
Yes
No
Is your current housing classified as “affordable housing”? (i.e. is your rent based on your income?)
Yes
No
How long have you lived at your current location?
How many times have you moved in the last 3 years?
Why did you move from your last residence?
Homeless Status: Have you ever stayed in a shelter?
Yes
No
If so, when?
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Monthly Household Expenses
Does your household have these basic utilities:
Phone
Gas/Propane
Water
Electricity
Have you been able to pay your utility bills on time?
Yes
No
Are you currently enrolled in any utility assistance programs?
Yes
No
Please list amount of monthly amount spent on the following:
Utilities (gas, electric, water, & phone combined)
Food Expense
Transportation
Insurance
Other Debt Payments (credit cards, loans, car notes combined)
Rent Amount
Total Household Monthly Expenses:
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Self Assessment
In your opinion, what are top 3 problems that are threatening your current housing situation and/or have put you in the position of needing help with your rent?
In your opinion, what are top 3 problems that are threatening your current housing situation and/or have put you in the position of needing help with your rent?
In your opinion, what are top 3 problems that are threatening your current housing situation and/or have put you in the position of needing help with your rent?
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Release of Information
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Signature
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