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

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 62+) 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

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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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