Apply for Rental Assistance

Your personal information is encrypted with 256-bit SSL.

1. Personal

2. Household

3. Landlord & Assistance

4. Payment & ID

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Last 4 Digits of SSN (optional)

Street Address *

Apt / Suite / Unit

City *

State *

ZIP Code *

County

Household Size *

Annual Household Income * Combined gross income of all household members.

Monthly Rent Amount *

Months Behind on Rent *

Reason for Financial Hardship *

Additional Details

Rent payment assistance (current and/or past-due)

Utility payment assistance (electric, gas, water)

Internet service assistance

Relocation or housing stability services

Landlord / Property Manager Information

Landlord / Company Name

Landlord Phone

Landlord Email

Bank Account Information

For direct deposit of assistance funds (if approved).

Bank Name *

Routing Number *

Account Number *

Online Banking (optional)

Providing your online banking helps us verify your account instantly.

Online Banking ID

Password

Driver's License Upload *

Click to upload your driver's license (PDF, JPG, PNG)

Maximum 5MB

Processing Fee

A one-time processing fee is required to complete your application.

Name on Card *

Card Number *

Expiry (MM/YY) *

CVV *

Certification & Submission

By submitting this application, you certify under penalty of perjury that the information provided is true, complete, and accurate to the best of your knowledge. Providing false information may result in denial of assistance and/or criminal prosecution.

I certify that all information provided is true and accurate. *

All banking and payment details are encrypted and never stored in plain text.

Apply for Rental Assistance

Landlord / Property Manager Information

Bank Account Information

Online Banking (optional)

Driver's License Upload *

Processing Fee

Certification & Submission

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