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 submit 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:
Been Unemployed for more than 90 days.
Qualified for unemployment benefits.
Experienced a reduction in income directly or indirectly due to COVID-19.
Incurred significant costs directly or indirectly due to COVID-19
Experienced other financial hardships directly or indirectly due to COVID-19.
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:
Received a past due rent notice?
Received a past due utility notice?
Received an eviction notice?
Lived in unsafe or unhealthy conditions?
Experienced any other risk of homelessness?
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. ______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
