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Provide the tenant contact information.

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Tell us how to reach the landlord:

The following questions pertain to the tenant and should only be completed by the tenant.

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What is your race/ethnicity?

Select a response

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What is your gender?

Select a response

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Please provide the Social Security Number and Date of Birth for the primary applicant.

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Are you:

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How many adults live in the household?

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How many total people live in the household?

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Please provide household member information:

You will use the following format and repeat until all members are listed:

First Name Last Name

Gender

Date of Birth

Member Relationship to Primary Applicant

(Repeat if necessary, skip if single)

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Tell us what has caused you to need rental assistance?

I contracted COVID-19 which impacted my ability to work
COVID -19 impacted my place of employment (I lost my job or my hours/salary)
I currently have health issues that prevent me from working
I have applied for or received unemployment assistance in the last 12 months
Childcare options have been impacted due to COVID-19
Other: please describe
Closed to responses

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Please indicate all sources of income for the household, even unrelated individuals.

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Please provide your household income including any gross salary, business net income, rental real estate income, social security, overtime, tips, bonuses, interest & dividends, pensions, unemployment, worker's comp, alimony, child support, welfare payments, TANF, other income

Provide the most recent income in the following format:

weekly

bi-weekly

monthly

If you don't have income, put N/A

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Please provide your employer name, address, and phone number:
If you are unemployed, retired, or disabled, list N/A below.

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Have you applied for assistance from any of the following agencies in the past 12 months ? (Application does not mean automatic disqualification).

Other
42%
Community Action Partnership (CAP) of Greater Dayton)
30%
Catholic Soclal Services
10%
Goodwill Easter Services
8%
State of Ohio
8%
Homefull
7%
Salvation Army
6%
Greater Dayton Apartment Association
2%
Closed to responses | 194 Responses

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Have you received PRC (Prevention/Retention/Contention) since July 1, 2020?

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Has a 3-day notice or eviction been filed against you?

Yes, a 3-day notice
Yes, an Eviction filing
No, but I'm behind in my rent
No, but I can't pay my rent this month
Closed to responses

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Have you filed eviction declarations?

An eviction declaration is a form you complete and give to your landlord stating you aren't eligible to be evicted and why. You can see a sample here:

https://www.cdc.gov/coronavirus/2019-ncov/communication/EvictionProtectDeclare_508.pdf

No
95%
Yes
5%
Closed to responses | 329 Responses

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Have you ever received rental assistance of any kind?

No
73%
Yes
27%
Closed to responses | 331 Responses

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Have you applied to any other agency for funding for the rent and/or utilities for the last 12 months or the future 3 months?

No
79%
Yes
17%
Im not sure
5%
Closed to responses | 222 Responses

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Any important information you want staff to know about? (Such as plans to move out, recent job loss, utilities shut off, etc?)

Tell us more:
100%
Closed to responses | 106 Responses