Shelter Arrears Assistance Questionnaire
Erie County Department of Social Services
Division of Family Independence | Temporary Assistance
Head(s) of Household/Tenant(s) of Record at your address
Please provide lease or landlord form (completed by owner or property manager only) with application.
1. Explain, in detail, what has caused you to fall behind on your rent, mortgage, or taxes for the
You may be required to submit verification of this reason.
2. Are there any other adults in your household responsible for paying a portion of the rent,
mortgage or taxes?
If yes, who? And how much is their portion?
3. Do you, or are you going to, receive any rental assistance from an outside agency that pays
a portion of your rent/mortgage each month?
Pending Receiving N/A
Type of Rental Assistance (Please provide portion letter with application)
Evergreen Health Services
4. What income and resources do you have available to pay your future rent, mortgage, or
taxes each month?
All income and resources must be verified to determine eligibility.