Her Haven Emergency Housing Funds Application

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Application for emergency funding for up to two months rent to avoid eviction and/or because I am escaping violence.

Full Name *

Driver's License Number *

Number of children living with me/ ages *

The following describes my circumstances (check all that apply): *

I am a single mother- I do not have a partner living with me or helping to support my children

I require housing to keep myself and my children safe.

I am facing eviction.

I can avoid eviction if I am provided with two months' rent.

I am seeking help with a housing deposit and/or first month’s rent for permanent housing.

I am seeking up to two months rent for a new apartment.

Required

My current address is: *

My occupation status is: *

employed

unemployed

My monthly rent is: *

My plan for long-term housing is (please share how this monetary assistance will help you achieve permanent and sustainable housing):

My contact information (provide email and cell phone): *

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