Rapid Response Application
Please complete this application to apply for financial assistance that will prevent homelessness. After submitting your application, a staff member will reach out to you.
Name *
Current Address (if homeless, type homeless) *
Phone Number
Email Address
Preferred language (English, Spanish, Portuguese, etc.) *
For ALL household members please list (1) Full Name (2) Relationship to the head of household (3) Date of Birth (4) Age (5) Sex *
Is a change of household composition expected? If yes, what type of change and when? *
Ethnicity *
Race of Household
Clear selection
Check all that apply to you *
Required
What type of assistance are you in need of? (Please explain in detail) *
How much assistance do you need? (dollar amount, by when?) *
The circumstances behind why you need assistance *
Have you received assistance from other agencies? From what agency, how much, when and why? *
How will you be able to pay your expenses after assistance? *
What difficulties do you expect in maintaining your monthly espenses? *
How much are you able to pay towards your debt? *
Are you in need of assistance with food, clothing, or furniture? *
Check all that apply to your household: *
Required
If your household receives any non/cash benefits, please list which benefits you receive and how much you receive (ex: SNAP, MRVP, Section 8, WIC, TAFDC Childcare, TAFDC Transportation, Public Housing) *
Please select the option that applies to your household: *
Does anyone in your household receive wages from employment? If yes, how much do they receive monthly? *
Does anyone in the household receive SSI or SSDI? If yes, how much do they receive monthly? *
Does anyone in the household receive unemployment? If yes, how much do they receive monthly? *
Does anyone in your household receive EAEDC or TAFDC? If yes, how much do they receive? *
Does anyone in the household receive child support? If yes, how much do they receive and how often? *
Please list any other household income.
Does anyone your household have a bank account? If so, please report the following for each account: 1) the type of account 2) the current cash value in the account 3) any interest rates that may apply *
If applicable, please provide us with contact information for your landlord (name, address, and phone number)
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