PASS Application
Any documentation requested in the application can be emailed to or dropped off at the Somerville Homeless Coalition office at 1 Davis Square from Monday-Friday between 2:00-4:00. The office entrance is on Dover Street.
Applicant Name *
Current Address *
Home Phone
Alternate Phone
For ALL household members please list (1) Full Name (2) Relationship to the head of household (3) Date of Birth (4) Age (5) Sex (6) S.S# *
Ethnicity *
Race of Household
Clear selection
Check all that apply to you: *
Check all that apply to you: *
Check all that apply to you:
Landlord Verification: List your current landlord. If you are staying in a shelter, with family or friends provide information for the most recent landlord information prior to homelessness. (1) Landlord name (2) Address (3) Telephone Number *
Income Information: What is the total annual income of all household members? Include wages, salaries, tips, AFDC, Social Security, and any other income such as alimony, and child support. For ALL household members please list (1) Full Name (2) Source of Income (3) Annual Amount *
Asset Information: List the type and source of any family assets. Provide both the current cash value and the estimated annual income from the asset. For ALL household members please provide (1) Full Name (2) Type and Source of Assent(e.g. bank accounts, investments) (3) Cash Value of Asset (4) Annual Income from Asset *
Debt Information: List all debts you have currently. For ALL household members please list (1) Full Name (2) Type of Debt(e.g. car loans, school loans, credit cards) (3) Current Debt Amount (4) Monthly Payments *
What is the asking rent for your apartment? $ *
Are there any utilities included in your rent? *
If the above answer is yes, list utilities included in rent: *
Has your landlord raised your rent recently? *
If the above answer is yes, when? And how much was the rent raised? *
How many bedrooms in your current unit? *
How many individuals live in your current unit (including you)? *
Do you anticipate any changes in your household size? *
By typing my name below, I certify all information in this application is accurate and complete to the best of my knowledge and belief. I understand that false statement or information are criminal offenses punished under state and federal law. I also understand that false statement or information are grounds for rejection of this application or termination of tenancy. Furthermore, the applicant agrees to notify the Somerville Homeless Coalition, Inc. of any material changes in income and assets from the date of application up to until the assistance if distributed. Finally, certification may be obtained from any source herein. I/We understand that the above information is being collected to determine if I/we are eligible to receive rental assistance. I/we authorize the administrator(s) of the PASS Program to verify all information provided on this application. Head of Household signature and other member of household over age 18. (Please type names in lieu of signature below) *
TENANT GOAL PLAN - Please describe in detail the following: (1) Your goal(s) for the next year (2) How the PASS Program can help you reach your goal(s) (3) Difficulties you expect in reaching your goal(s) *
In this section, please check to acknowledge which documentation needs to be provided in support of your application, Please submit requested documents via email to Erin Reilly at or by dropping them off at the SHC office located at 1 Davis Square in Somerville. The office is open Monday-Friday 2:00pm-4:00pm. The entrance in off of Dover Street. Applications will not be processed until requested documentation is received.
Never submit passwords through Google Forms.
This form was created inside of Somerville Homeless Coalition, Inc.. Report Abuse