Housing & Utility Assistance Program Application


PLEASE MAKE SURE THAT REQUIRED FIELDS BELOW ARE FILLED. UPLOAD ALL SUPPORINTG DOCUMENTS AND ATTACHMENTS OTHERWISE YOUR APPLICATION WILL BE REJECTED.

Housing: Rent/Mortgage/Utility Payment Program

  • Section 1: Type of Assistance Requested: Please check all types of assistance requested

  • Section 2: Household Demographics

  • Applicant Information

  • Date Format: MM slash DD slash YYYY
  • Co-Applicant Information [If applicable]

    Co-applicant could be your spouse or significant other residing in the same household with you
  • Section 3- HOUSEHOLD INFORMATION, INCOME AND EMPLOYMENT INFORMATION

  • Name (First, Middle, Last)AgeGender (Male, Female)Relationship to applicant 
  • Name (First, Middle, Last Name)Employment; Unemployment /Workers Comp $Social Security/ SSDI VA Disability: $TANF/WIC $Retirement, VA Benefits, Pension $Other Income $ 
  • Employment Information

  • HOUSING INFORMATION- LEASE/RENT (ONLY)

    Fill this section ONLY if you are leasing/renting an apartment of a house and need help with your monthly payment
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • HOUSING INFORMATION- MORTGAGE

    Fill this section ONLY if you own a house with a mortgage payment and need help with your payment
  • UTILITY ACCOUNTS INFORMATION

  • Water Bill

    Fill this section if you need help with your water bill [Must provide a copy of the bill you need help with in the attachment section below]
  • Gas Bill

    Fill this section if you need help with your gas bill [Must provide a copy of the bill you need help with in the attachment section below]
  • Electric Bill

    Fill this section if you need help with your electric bill [Must provide a copy of the bill you need help with in the attachment section below]
  • FINANCIAL HARDSHIP QUESTIONNAIRE/SCREENING QUESTIONS

  • Please complete the requested information

    Place a check mark next to the statement that most closely reflects your current situation since the COVID-19 Disaster Declaration
  • EMPLOYMENT:

    COMPLETE REQUESTED INFORMATION AND CHECK ALL THAT APPLY A determination of financial hardship due to lost employment or income either permanently or temporarily due to the effects of the COVID-19 pandemic.
  • Housing/Rental Assistance:

    COMPLETE REQUESTED INFORMATION AND CHECK ALL THAT APPLY. [A determination of housing crisis due to lost employment or income either permanently or temporarily due to the effects of the COVID-19 pandemic].
  • If this option does not apply to you, type N/A
  • List date of eviction notice below and when it will take effect (If this option does not apply to you, type N/A)
  • (Choose one option)
  • Utilities

  • A determination of hardship and inability to pay for basic utilities due to lost employment or income either permanently or temporarily due to the effects of the COVID-19 pandemic. Basic Utilities include: Water, Electric, Gas
  • Personal Statement Section:

  • By typing my name above, I herby sign the release of information consent above
  • Name (First, Middle, Last)Phone NumberToday's Date 
    By Typing the name (s) above, you consent to sign WARNING: The information provided in this application form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making a false or fraudulent statement to a department of the United States Government, and may be fined not more than $10,000 or imprisoned for not more than five years, or both. This information will be used to establish a level of benefit for HUD and other Federally funded program(s); To protect the government’s financial interest; and to verify the accuracy of information furnished. It may be released to appropriate Federal, State, and Local Agencies when relevant to civil, criminal or regulatory investigators, and prosecutors. Failure to provide any information may result in a delay or rejection of eligibility or approval.
  • THIS AFFIDAVIT MUST BE EXECUTED BY ADULT HOUSEHOLD MEMBER(S) WHO ARE 18 YEARS OLD AND OVER AND DON’T HAVE ANY SOURCE OF INCOME

    if no income, please complete this section
  • Name (First, Middle, Last)Today's Date 
    By Typing the name (s) above, you consent to sign
  • Client Rental/Utility Assistance Duplication of Benefits Certification Form

    This section must be filled out by applicant and/or co-applicant
  • ACCESS AND LAHC ARE OFFERING THE SAME ASSISTANCE PROGRAM. YOU CAN ONLY APPLY TO ONE ORGANIZATION, OTHERWISE YOUR APPLICATION WILL BE REJECTED

  • By typing my name above, I herby sign the Client Rental/Utility Assistance Duplication of Benefits Certification Form
  • Date Format: MM slash DD slash YYYY
  • Attachments Section:

  • Upload Documents: Maximum file size allowed is: 10MB

  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    Maximum file size allowed is: 250MB
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    Maximum file size allowed is: 10MB
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
  • DECLARATION OF SECTION 214 STATUS

    Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the U.S. Read the Declaration statement carefully then sign. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    Maximum file size allowed is: 10MB
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    Maximum file size allowed is: 250MB
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    Maximum file size allowed is: 250MB
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    Maximum file size allowed is: 250MB
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    (jpg, gif, png, pdf Only)
  • By signing my name, I certify that the information presented in this form is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations here- in constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of funds
  • Date Format: MM slash DD slash YYYY
  • By signing my name, I certify that the information presented in this form is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations here- in constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of funds
  • Date Format: MM slash DD slash YYYY