Rent, Mortgage, and Utility Assistance Application

Housing Help Center Intake Form

Our navigators are still working on your case and will be in touch. Please reach out to EMAIL@AtlantaGA.gov if you need additional assistance.

Contact Information

First Name

Last Name

Date of Birth

mm/dd/yyyy

Phone number

Email address

If you do not have an email address, please input yourname@noemail.com

Home Street Address

Input your street address and apartment number(if applicable)

City

State

What Georgia County do you live in?

Enter other county (Please note we can not guarantee assistance based on your geographic location outside the Atlanta Metro area)

Zip Code

Enter other zip code (Please note we can not guarantee assistance based on your geographical location outside the Atlanta Metro area)

How would you like us to contact you?

Landlord Contact First Name

Landlord Contact Last Name

Landlord Contact Phone Number

What is the address of your future residence?

Input your street address and apartment number(if applicable)

City

State (2 Letter Abbreviation)

Zip Code

How much is your outstanding water bill(s)? (Please note we cannot guarantee the specific amount requested will be met)

Input value without commas

What amount can you put towards this water bill?

Input value without commas

Please explain what other utility bill needs support

How much is your outstanding "other utility" bill? (Please note we cannot guarantee the specific amount requested will be met)

Input value without commas

What amount you can put towards this other utility bill?

Input value without commas

Thank you for filling out this form. Please press Submit when you are ready