Fillable TENANT ASSISTANCE APPLICATION

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TENANT ASSISTANCE APPLICATION

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The TENANT ASSISTANCE APPLICATION form is 4 pages long and contains:

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  • 12 check-boxes
  • 45 other fields

Country of origin: OTHERS
File type: PDF

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Draft 2.3.2021
TENANT ASSISTANCE APPLICATION
CONTACT INFORMATION
1. What is your name? ______________________________________________________________
2. What is your phone number? ______________________________________________________
3. What is your e-mail address? ______________________________________________________
4. What is the address of the leased property? (Street, Unit #, City, County and Zip) If you have
already vacated the leased property, what is your current address? (Street, Unit #, City, County,
and Zip)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PERSONAL INFORMATION
5. What is your social security number? ________________________________________________
6. What is your date of birth? ________________________________________________________
Example: January 7, 2019
7. What is your race?
Mark only one.
o American Indian or Alaska Native Asian
o Black or African-American
o Native Hawaiian or Other Pacific Islander White
o Other
8. What is your ethnicity?
Mark only one.
o Hispanic/Latino
o Non-Hispanic/Latino
9. What gender do you identify as?
Mark only one.
o Male
o Female
o Transgender Female to Male
o Transgender Male to Female
o Non-Conforming
Draft 2.3.2021
10. What is your annual income? ______________________________________________________
Please email a copy of wage statement(s), unemployment benefit statement(s), or tax return(s)
when you submit your application. Documentation is required.
HOUSING/UTILITIES INFORMATION
11. How many total people live in the household? ________________________________________
12. How many adults live in the household? _____________________________________________
13. How many children live in the household? ____________________________________________
14. Do you have a current lease?
o Yes
If yes, what is the expiration date of your current lease? ________________________________
Please email a copy of the lease and any documentation of payments pursuant to the lease when
you submit your application. Documentation is required.
o No
15. How much do you currently owe in past due rent arrearage accrued since March 31, 2020? ____
16. What is the name of your Landlord/Property Manager? _________________________________
17. What is the contact information for your Landlord/Property Manager? _____________________
18. If applicable, what is your Court Case number? ________________________________________
Please email a copy of your Magistrate Court Notice when you submit your application if
applicable.
19. Do you have past due utilities? Yes__________ No___________
20. If yes, list the name and contact phone number of the utility company and how much you owe
on all that apply. (If you pay your utilities to your Landlord, put Landlord as the company name)
a. Water: Amount $ ________Company ______________ Phone _____________
b. Electricity: Amount $ ________Company ______________ Phone _____________
c. Gas: Amount $ ________Company ______________ Phone _____________
Please email a copy of any past due and pending utility bills noted above when you
submit your application.
21. Has one or more individual within the household experienced any of the following conditions
since March 31, 2020? Please check all that apply:
o Been Unemployed for more than 90 days.
Draft 2.3.2021
o Qualified for unemployment benefits.
o Experienced a reduction in income directly or indirectly due to COVID-19.
o Incurred significant costs directly or indirectly due to COVID-19
o Experienced other financial hardships directly or indirectly due to COVID-19.
o None of the above apply.
Please attach documentation of the unemployment (including date of termination and name of
prior employer), approval for unemployment benefits, reduced income, and costs or other
financial hardship if you have such documentation when you submit your application.
22. Is one or more individual within in the household at risk of homelessness due to any of the
following factors?
Please check all that apply:
o Received a past due rent notice?
o Received a past due utility notice?
o Received an eviction notice?
o Lived in unsafe or unhealthy conditions?
o Experienced any other risk of homelessness?
o None of the above apply.
Please attach any documentation of the of the above if you have such documentation that
has not already been attached when you submit your application.
23. Does your household currently receive rental assistance? If so, please list the sources of that
assistance below. ______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DECLARATION
Under the penalty of perjury, I declare the information provided in this application is true and
correct to the best of my knowledge. I further state that my inability to pay rent occurred on
or after March 13, 2020, as a result of COVID-19.
WAIVER
I hereby acknowledge that this application for rent assistance in no way guarantees a resulting
grant of assistance. I further acknowledge and agree that I voluntarily and freely submit this
application recognizing that DeKalb County is not liable for the security of any personal
information provided with this application and I waive any and all claims against DeKalb
Draft 2.3.2021
County, its officials and employees, known or unknown, resulting from or related in anyway to
this application and any of the personal information included with this application.
_______________________________________ _________________________
Signature Date
Please sign by typing your name and the date.
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TENANT ASSISTANCE APPLICATION

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Completed 12 February 2021

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