Housing Assistance Application Form

Today's Date*

MonthDay Year

Name*

First Name Middle Name Last Name

Legal Name if different

First Name Middle Name Last Name

Date of Birth*

MonthDay Year

Address

Street Address

Mailing Address

City State / Province

Postal / Zip Code

Phone Number

Email

example@example.com

Has your household been adversely impacted by the Covid-19 Pandemic?*

YesNo

Have you received COVID-related rent relief?*

YesNo

Ethnicity*

Race*

Gender*

Additional Household Members

Are you or anyone in your household living with a disability?*

YesNoDecline to answer

Are you or anyone in your household a Veteran?*

YesNoDecline to answer

I am requesting assistance for the following:*

Household Type*

Choose the option that best represents you.

Current Housing*

Choose the option that best represents you.

Income total income from all sources in the last 30 days*

Enter Zero if No Income

Statement of need/Income explanation

Explain any impacts to income sources.

Vendor *

Who do we need to pay?

Vendor Phone Number

Vendor Address to Mail Check*

Mailing Address

City State

Zip Code

Amount Requested*

I understand that it is against the law to make false statements, and that I am subject to prosecution if I do.
▪ I authorize the release of information from my rental/utility vendor(s) to the
Humanity In Progress (HIP) and further authorize the HIP to communicate with my vendor(s) on
my behalf as it relates to the Assistance Program.
▪ I understand that my household can submit only "one" application for Assistance per program year and that the home I am applying for is the home I
live in.
I understand that HIP will confidentially use this information to provide improved
services and acquire other grants. I certify that the information given above is true and complete to the best of my knowledge. I am signing knowing I am the designated representative of my whole household and this is the only application submitted for the members of this household. I understand that providing false or misleading information regarding anyone in my household is fraudulent and may be subject to criminal penalties.
By signing, I certify that I have read and understand the above agreement.

Applicant Signature*

Clear

Please verify that you are human*

Housing Assistance Application

Household Income Information

Vendor Information (Landlord, Utility Company)

Signature Page