SHELTER, Inc. : Rental Assistance Self-Service Registration : Rental Assistance Application

First Name (Required)

Please type your first name

Last Name (Required)

Please enter your last name

Email (Required)

Enter your Email address

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Phone (Required)

Enter your Area Code and Phone Number as ###-###-####

Address (Required)

Enter your Street Address

City (Required)

Enter your City

ZIP Code (Required)

Enter your ZIP Code

Adults (Required)

Enter the number of Adults (18 years and older) in your household

Seniors (Required)

Enter the number of seniors (age 65+) in your household

Minors (Required)

Enter the number of Children (less than 18 years old)

Pre-COVID Income (Required)

Enter your pre-COVID household monthly income

Current Income (Required)

Enter your current household monthly income

Reason (Required)

Please choose the reason for your change in income

Job Documentation

Do you have documentation for your job situation?

Job Documentation

Yes
No

Monthly Rent (Required)

Enter your current monthly rent amount

Monthly Rent

Months Needed (Required)

How many months of rental assistance do you need?

Utilities Owed

Are you behind on paying utilities?

Yes
No

Utilities Amount (Required)

How much do you owe in past-due utilities?

Your Utilities

Please check the boxes for your past-due utilities

Your Utilities

None
Garbage
Gas Electricity
Internet
Phone
Water

Phone Times

What are the best times to call you Monday-Friday - check all that apply

9am-11am
11am-1pm
1pm-3pm
3pm-5pm
5pm-7pm
7pm-9pm

Rental Assistance Application

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