Hamilton County CARES Act Rent and Utility Assistance Application
1. Have you or a member of your household suffered an adverse financial event as a result of COVID 19?
No; Yes – If yes, please describe.
2. Has that financial loss affected your ability to pay your rent or utility bills? No; Yes – If yes, please specify how, and specify
amount of rent/utilities that is owed
My family’s financial loss has affected my ability to pay rent or utility bills as described here:
The amount of rent/utilities owed is: (Must submit supporting documentation from landlord/utility provider)
Rent owed: $ Utilities owed: $
Do you currently live in Hamilton County?
Have you experienced a decrease in income due to COVID-10 pandemic?
Do you have past due rent and/or utilities?
Do you have the ability to pay your rent and utilities right now?
Have you received other rent/utility assistance since March?
Has your landlord received other payment for the past due rent/utilities?
9. Household Members (include yourself) Household members include the applicant, their children, spouse, and/or co-parent of
any child in the home.
Household Income for the Past 30 Days
Employment, Child Support, Unemployment Benefits, Social Security, TANF, Alimony, Etc.
HCJFS 0147 (REV. 11-20)