Rapid Response: Start-up Costs

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this application only if you are moving into new housing and need assistance with start up costs (first, last, security, movers). Please note that prior to applying, you should have identified a unit to move into and have a plan to pay for the rent moving forward. After submitting your application, a staff member will reach out to you.

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.) *

For ALL individuals moving into the unit please list (1) Full Name (2) Relationship to the head of household (3) Date of Birth (4) Age (5) Sex *

Will there be any other individuals living with you in the new apartment that are not part of your household? (Roommates, friends, other family members, etc.) *

Yes

Maybe

What is your current living situation?

I am staying in an emergency shelter

I am staying in a place not meant for human habitation (ie. car, outside, etc.)

I am staying with friends or family and can stay as long as I need to

I am staying with friends or family but have been given a date I need to leave by

I am currently in an apartment I rent

Other:

Clear selection

Why are you moving? *

I am homeless or staying with friends and family and I am moving into an apartment

I can't afford the rent where I am currently staying and need a more affordable unit

My current apartment is not safe

I received a mobile housing voucher and cannot apply it to my current unit

I am being evicted from my current apartment

Other:

Please list the address for the NEW unit you will be moving into. *

What is the move-in date for your new unit? *

What is the monthly rent for your new unit?

What type of lease arrangement for your new unit?

Written lease agreement between me and the landlord

Oral lease agreement between me and the landlord

Subletting from a current tenant (the landlord knows I am moving in)

Subletting from a current tenant (the landlord does not know I am moving in)

Other:

Clear selection

Will you have roommates in your new apartment? *

Yes

Other:

How do you plan to afford the rent for your new unit moving forward? *

I have a mobile voucher (Section 8, MRVP, etc.)

The unit is subsidized (rent is based on my income)

My household income is sufficient to afford the rent

I will not be able to afford the rent moving forward

Other:

What type of assistance are you in need of? (Check all that apply) *

First month's rent

Last month's rent

Security deposit

Moving assistance

Utility deposit (if required by utility company)

Other:

Required

Which of the following explain any COVID-related aspects of your need for assistance: *

My need for assistance is not COVID-related

I lost employment due to COVID

I work fewer hours and earn less money due to COVID

My household's expenses have increased due to COVID

Other persons in my household lost all or part of their income due to COVID

Other persons who were helping to pay the rent moved out due to COVID

Other:

Check all that apply to your household: *

A member of the household is employed

A member of the household expects to work in the next 12 months

A member of the household works for someone who pays them in cash

A member of the household receives or expects to receive child support

A member of the household receivers or expects to receive alimony payments

A member of the household is not receiving child support or alimony payments they are entitled to

A member of the household receives unemployment benefits

A member of the household receives or expects to receive welfare payments (SSI, TAFDC, EAEDC etc)

A member of the household receives or expects to receive Social Security benefits

A member of the household receives income from a pension or annuity

A member of the household receives regular financial contributions from someone outside of the household (ex: family, friends, agencies)

A member of the household receives income from assets such as stocks, bonds, or interest from a bank account

A member of the household expects to receive an earned income tax credit

A member of the household owns a home or other property

A member of the household has sold or given away property within the last two years

None of the above

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) *

Please provide us with contact information for your new landlord (name, address, email address and phone number)

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Somerville Homeless Coalition, Inc..

Does this form look suspicious? Report

Forms