COVID-19 RENTAL RELIEF APPLICATION

Applicant Contact Information (Must Be Named on Rental Agreement)

First name

Last name

Phone

Address line 1 (no PO boxes)

Address line 2

City

State

Zip code

Household Information

Number of adults ages 18-59, including applicant

Number of children ages 0-17

Number of adults ages 60+, including applicant

Number of household members receiving income, including applicant

Financial Assistance Information

Assistance cannot be applied towards taxes, fees, or deposits.

Please describe how the COVID crisis has led to your financial need (e.g., job loss, illness, unexpected expense, changes in household size)

Monthly rent amount (round all cash amounts to nearest dollar)

Assistance amount requested (cannot be more than one month's rent)

To be applied to

Current month's rentLate rent

Due date

Original due date

Total rent amount owed, including current month

Household Monthly NET Income

Has any household member's working status been affected by the COVID crisis?

YesNo

If unemployed but scheduled to return, please provide return date

Please report income amounts below for the ENTIRE HOUSEHOLD.

All income must be DOCUMENTED.

Provide AFTER-TAX or NET amounts.

If you have no income in a category, please type 0. Round to nearest dollar.

Work earnings

Retirement/pension

Child support

SNAP benefits

Social Security Income/Social Security Disability Income

Disability/Unemployment/Workers Comp

Other income (must be documented income)

Total funds in savings, checking, or investment accounts

Household Monthly Expenses

Please report expense amounts for the ENTIRE HOUSEHOLD.

If you have no expenses in a category, please type 0. Round to nearest dollar.

Household Housing Expenses

Rent (do not include any fees, deposits, etc.)

Heating oil/gas

Electric

Water/sewer

Trash

Rental insurance

Household Transportation Expenses

Car payment

Car insurance

Public transit costs

Other Household Expenses

Cell phones

Cable/internet

Student loans

Daycare costs

Child support

Food/household supplies

Other expenses (please explain)

Additional expenses expected within the next 30 days (type, amount, and due date)

By clicking Submit, I attest that:

I live at and am responsible for the rent to which this funding will be applied.
I am the head of household/lessee.
My household has not/will not receive any other CARES rent assistance from a Montgomery County agency between 1/27/2020 and 5/31/2021.
I have provided complete and accurate household financial information.
I have provided complete and accurate contact information for my landlord.
I will provide all required supporting household documentation (copy of rental agreement/lease; income, bank, utility, loan documents; proof of childcare expense; etc).

Contact Information