Homeless Prevention Fund Request Form
Applicant Information
Full Name
Date of Birth
Current Address
Phone Number
Email Address
Household Information
Number of People in Household
Names and ages of household members
Housing Situation
Current Housing Situation
Renter
Homeowner
Doubled-up / Staying with Others
Emergency Shelter
Unsheltered
Other
How are you at risk of homelessness?
Request Details
Amount Requested
Purpose of Funds (e.g. rent, utility, other)
Brief Description of Need
Income & Employment
Income Source(s)
Monthly Gross Household Income
Employment Status
Employed
Unemployed
Other
Significant changes to income in past 6 months
Landlord/Property Information (if applicable)
Landlord/Property Manager Name
Landlord Contact Information
Consent & Declarations
I certify that the information provided is true and complete.
I consent to be contacted regarding this application.