Rental Assistance Application for the CCN Homelessness Prevention and Rapid Re-Housing Program

Name *
Name
Date of Birth *
Date of Birth
Gender *
Is participant a legal resident of the United States? *
If no, participant is ineligible for this program. Do you understand? *
Is participant currently employed? *
If no, participant will need to provide unemployment documentation. Do you understand? *
Does participant report any other source of income?
Are there any other household members with income?
$
$
Is a signed lease agreement in participant's name provided?
Is participant's rent subsidized? (If yes, then participant is not eligible for rental assistance).
Is participant responsible for utilities (Are they in participant's name)? If no, participant is not eligible for utility assistance.
Was participant evicted from previous housing?
If yes, please list the date of eviction.
If yes, please list the date of eviction.
Was participant previously residing in a shelter, car, tent, woods, etc.?
If participant was residing in a shelter previously, documentation will be needed. Do you understand?
I understand by signing this that any assistance received in temporary and I will continue to be responsible for maintaining my living expenses. Also, I agree not to sublease the rental unit as long as rental assistance is received. I certify that the information I have provided is true and correct to the best of my knowledge. Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.
I understand by signing this that any assistance received in temporary and I will continue to be responsible for maintaining my living expenses. Also, I agree not to sublease the rental unit as long as rental assistance is received. I certify that the information I have provided is true and correct to the best of my knowledge. Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.
Date Signed
Date Signed