Thank you for contacting Mesa CARES. This COVID Crisis Rental Assistance program was established in response to a Public Health Emergency due to the COVID-19 pandemic and the related evictions and utility turn-offs. We are here to help.

The program provides financial assistance to households in the City of Mesa who experienced financial hardship as a direct result of COVID-19 pandemic. Please take the time to complete this application.

If you have questions, please call 480-644-CARE (2273) for assistance. Once the application is completed, you will hear from us within five business days.

What type of assistance are you applying for?*

Utilities Rent Utilities & Rent

Are you a resident of the City of Mesa?*

Yes No

Have you or a family member in your household been financially affected by COVID-19?*

Yes No

How many people currently live in your home?*

All people in your household, not just family

What is the combined gross household income for all adults living in the home in the last 30 days? *

Pre-tax income from ALL adults who are 18+ years (not in high school), living in the home

Does your household meet 300% poverty guidelines for household size?*

Yes No

Have you received a notice from the City of Mesa about a scheduled utility turnoff?*

Yes No

The City of Mesa will notify you as soon as possible regarding an award. If you do not receive a notification after 24-hours or if your utilities get turned off, please call Mesa Customer Service at 480-644-2273.

Thank you for contacting Mesa CARES. Unfortunately, this program is only available to Mesa residents who have experienced a financial hardship directly due to COVID-19 and who meet income eligibility requirements. If you live outside of Mesa, please go to the Maricopa County website for assistance at:

https://www.maricopa.gov/5583/COVID-Crisis Rental-Assistance

If you are ineligible due to household income or any other reason, check out the Feeding Mesa Program and the Healthy Community Program at:

www.mesaaz.gov/mesacares

And, if you are interested in other federally-funded programs for low-moderate income households that are available now and post-COVID, go to A New Leaf's website at:

www.turnanewleaf.org or call 480-833-9200

Thank you and be well.

Are you currently experiencing any of the following as a result of COVID-19 (check all that apply)?

Gross monthly household income pre-COVID-19?

Current gross monthly household income due to COVID-19?

Applicant Name:*

First Name Middle Initial Last Name

Applicant Email:*

example@example.com

Date of Birth:*

Phone Number:*

Social Security Number:

Applicant Address:*

Street Address

Unit

City State / Province

Postal / Zip Code

Ethnicity:*

Hispanic:*

Yes No

Gender:*

Male Female

Preferred Language:*

English Spanish Other

Disability:*

Yes No

Do you receive subsidized housing?*

Yes No

If yes, list program name:*

Subsidized Housing Program Name

How much is your monthly Rent?*

How many months are you behind?*

Amount owed including fees?*

Landlord/Property Management Name*

Landlord Name:

First Name Last Name

Landlord Phone Number:*

Landlord/Property Management Email

Are Utilities included in your rent?*

Yes No

If yes, which utilities are included in rent at what monthly cost?

	Est. Monthly Utility Cost	Notes
SRP
SW Gas
City of Mesa
Other

Do you pay directly to a utility provider?*

Yes No

If yes, please complete additional information for each utility provider

	Monthly Utility Cost	Number of Months Behind	Amount Owed including fees
SRP
SW Gas
City of Mesa
Other

Has anyone in your household received rental assistance since March 1, 2020?*

Yes No

Name of Agency:

Date Received:

Months covered:

Total amount:

Has anyone in your household received utility assistance since March 1, 2020?*

Yes No

Name of Agency:

Date Received:

Months covered:

Total amount:

Gross household income for all member (except wages for persons under 18) will be considered in determining income eligibility for services. The gross amount of income (prior to deductions) received the past 30-days will be counted. Income includes, but is not limited to: employment wages (18 years +), social security, social security disability, unemployment, child support. Examples of documentation include:

Wages - paycheck stubs
Self-employment Income - business ledger
Social security/disability - current benefit award letter
Unemployment - award letter, printout of payments received
Child support- written verification
Babysitting/child care income - signed and dated statement by the person paying for the care
Housekeeper/home health aides - signed and dated statement by the employer
Retirement/Pension Income - Statement
Alimony - printout of benefit
Cash Assistance - print out/written statement by DES
Money provided to you by others such as family, friends, or other organizations

Households with no current income must complete a "zero" income form and submit one of the following:

1) written documentation from the income source of the last date employed and last date paid OR

2) Complete a self-certified form.

Please list all household member’s names (including the applicant) and include all income sources, amounts and dates received for the previous 30-days.

Click the +Add More button to add as many household members as needed. If there is no income for a household member, state “none” and complete Zero Income form.

Please provide documentation for each household member and for each source of income. See the Upload Required Documents section below.

Add ALL Household Members/Income (adults/children, not just family members, with or without income)*

Photo/scan of driver’s license or government ID of applicant

Document(s) showing COVID-19 financial impact

Income documentation for all household members for the last 30 days (from submission date)

Current lease agreement (required if applying for rental assistance)

Notice or letter from landlord identifying months late and total amount due (required if applying for rental assistance), W9, TIN Verification

Billing statement or notice of disconnect from utility provider(s) identifying months late and total amount due (required if applying for utility assistance)

AUTHORITY FOR RELEASE OF INFORMATION: By signing below, I agree to participate in the Emergency Services Network and utilize the City of Mesa/MesaCAN as my primary service agency. I authorize the City of Mesa/MesaCAN and/or delegate agency to contact any source necessary to establish the accuracy of the information given by me and to release or receive information contained on this form and/or in my case file.

APPLICANT’S STATEMENT OF TRUTH: Under Penalty of perjury and acknowledged by my signature below, I SWEAR or affirm that the statement made regarding the persons in my home, and the income, resources, property and all other items that pertain to my possible eligibility for benefits are TRUE and CORRECT to the best of my knowledge.

Applicant Name:*

First Name Last Name

Date*

Applicant Signature:*

Clear

Services funded by Maricopa County as part of the COVID-19 Cares ACT

Funding provided to the City of Mesa in partnership with MesaCAN

Equal Housing Opportunity

City of Mesa | MesaCARES | 480-644-2273 | Website

A New Leaf | MesaCAN | 480-833-9200 | Website

Rental & Utility Assistance Application

Eligibility & Household Information

Applicant Information

Lease & Utility Information

Gross Household Income Information

Household

Upload Required Documents

Release of Information

STAFF USE ONLY

Finance Review

Finance Review

Finance Review

Finance Review

Finance Review