Please confirm the spelling of your FULL name
What is your date of birth?
What gender do you identify with?
Are there any children (under 18) in the household?
For reporting purposes only, we are collecting the following demographic information. In thinking about ethnicity, which option best describes you
Also, for reporting purposes only, in thinking about race, which option best describes you? Please feel free to select more than one.
Have you been a resident of Montgomery County since at least February 2020?
Have you experienced a loss of income related to COVID that has prevented you from paying your rent? (reduction in hours, loss job, etc.)
Do you have a formal lease with your landlord/property? (There is a signed document between you and the landlord that clearly states how much rent is owned each month and what are the terms and conditions of staying in the apartment.)
What is the full address of your home? Please include apartment numbers and zip code
What is your monthly rent?
Do you currently have a summons from the District Court to appear for an eviction hearing? Or have you received a Red and White notice from the Sheriff's Office noting an eviction is imminent? This does not include notification from your landlord that they are filing for an eviction.
What is the date of your eviction hearing
Have you received assistance from any of the following programs in the last 60 days?
For any follow-up, including written requests, do you need information provided in any language besides English?
Did someone complete this form on your behalf?
I have assisted the named applicant in completing this form. I have submitted all information to be true to my knowledge, and have communicated with the applicant that this application will be submitted to Montgomery County Department of Health and Human Services, Services to End and Prevent Homelessness for evaluation and processing, and the applicant may be contacted for additional information. If I may be contacted to further assist with this application, I have included my contact information in the text box.
I certify that information provided above is accurate and complete to the best of my knowledge and belief. I understand that false statements or information will result in denial of assistance.
(If you have an email address where we can send you program updates and where your case worker can reach you at, please provide that here. If you don't have one please use firstname.lastname@example.org)
If available, please upload any copy of your rent ledger or a letter from your landlord that clearly states your monthly rent and amount owed. Please make sure the file name is your lastname.dateofbirth.rent. For example Smith.012782.rent
If available, please upload documentation that shows household income over the past 30 days and COVID impact. This may include a bank statement, pay stubs, or letter from employer noting termination/change of hours due to COVID, Please make sure file name is lastname.birthdate.income. For example Smith.012782.income1 and Smith012782.income2 (if uploading more than one document).