Rapid Response Application
For Somerville Residents Only. Please complete this application only if you are in housing and need assistance with paying your rent (including rental arrears) or utilities (must have a shut off notice). After submitting your application, a staff member will reach out to you.
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Applicant's Name *
If working with a case manager who will be assisting in your application, please list their name, agency and contact information.
Current Address *
Phone Number
Email Address
Preferred language (English, Spanish, Portuguese, etc.) *
Priority Status- please select the items below that apply to your household. This helps our agency prioritize applications. If one of the below categories is true, your case will be prioritized.
What kind of agreement do you have with your landlord? *
How much is your monthly rent?
Do you have a housing subsidy?
Clear selection
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? *
What type of assistance are you in need of? (Check all that apply) *
Required
How much assistance do you need? (dollar amount) *
Which of the following explain any COVID-related aspects of your need for assistance: *
If you owe rental arrears or utility arrears, why have you been unable to pay?
If you owe rental arrears, how were you able to pay your rent previously before the arrears began accruing? *
Will you be able to pay for your expenses after assistance? If yes, please explain how. If no, what is your plan for retaining your housing after assistance? *
Check all that apply to your household: *
Required
If anyone in your household receives wages from employment, please list their name and amount received monthly, *
If anyone in your household receives SSI or SSDI, please list their name and amount received monthly, *
If anyone in your household receives unemployment, please list their name and amount received monthly, *
If anyone in your household receives EAEDC or TAFDC, please list their name and amount received monthly, *
If anyone in your household receives child support, please list their name, amount received 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 approximate current cash value in the account 3) any interest rates that may apply (if known) *
If applicable, please provide us with contact information for your landlord (name, address, email address and phone number)
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