Housing

City of Dearborn Rent/Mortgage/Utility Payment Program

  • Applicant Information

  • Employment Information

  • Date Format: MM slash DD slash YYYY
  • FAMILY MEMBERS INFORMATION

  • Name (First, Middle, Last)AgeGender (Male, Female)Relationship to applicant 
  • Employment/ Unemployment/Workers CompSocial Security/ SSDI VA DisabilityTANF/WICPension, Retirement, VA Benefits, PensionOther Income- Alimony, Child Support, COVID19 Payroll Program Payments 
  • HOUSING INFORMATION- LEASE

    Fill this section ONLY if you are leasing/renting an apartment of a house
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • HOUSING INFORMATION- MORTAGE

    Fill this section ONLY if you own a house with a mortgage payment
    If NO, please fill out the section below
  • UTILITY ACCOUNTS INFORMATION

  • Date Format: MM slash DD slash YYYY
  • 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
  • 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
  • (Describe the need for assistance and how the household has been affected by the COVID-19 pandemic.)
  • 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.
  • AFFIDIVIT OF SOURCES OF ZERO INCOME

    THIS AFFIDAVIT MUST BE EXUCUTED BY ADULT HOUSEHOLD MEMBER
  • Client Rental/Utility Assistance Duplication of Benefits Certification Form

  • 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 and return to the address below. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.
  • (check the appropriate box, check only one)
  • By typing my name above, I herby sign this application
  • Date Format: MM slash DD slash YYYY