HHAP Rental Assistance What County do you live in? *Choose OneSan Bernardino CountyRiverside CountyWe have several programs to assist you depending on where you reside or became homelessHead of Household/Applicant infoHere we will gather general contact information to get us started. Please give yourself about 15 mins. to fill out this application.Is anyone in your household 55 years of age or older? *Choose OneYesNoIf anyone in your household is 55 or older we have special programs for seniorsAre you disabled?Are You Disabled?YesNoAre you disabled?Are you a referral from your medical provider? *Choose OneYesNoIf your medical provider referred you to us do not fill out this form. We will contact you.In a few short sentences please tell us why you are in need of assistance. *More information will be asked along with documentation for more details at a later time.Are submitting this request for assistance on behalf of *Choose OneMyself/My HouseholdFriend/FamilyDate *First Name *Middle Name *Last Name *Email Address *Phone *please input the best phone number to contact you.Street AddressIf currently homeless you may leave this part blankApartment, suite, etcCityState/ProvinceZIP / Postal CodeAge *Date of Birth *Household InformationHere we will ask you question about your family occupants to determine how we can best serve you.Are you or anyone in your household a veteran?Choose OneYesNoHow many people over 18 years old in your household with children (including yourself)? *What are the Names and Birthdates of the children in your homeIf no children respond with N/ADo you have any pets in your household? *Choose OneYesNoIs your pet certified/documented as a service animal?Choose OneYesNoIf yes, please identify number and type(s)?Occupancy & Transportationplease answer to the best of you abilityIn what city or community are you currently living/sleeping? *Where will you sleep tonight? *Choose OneFriends or family's houseMy own house or apartmentCarOn the street/in a park/in a garageEmergency ShelterTransitional Living/Sober Living/Medical RehabHow long have you been homeless/at-risk of homelessness?1-3 months3-6 months6-1Yeardoesn't apply /Not as risk at allIf necessary, are you willing to relocate outside of the area where you currently live/stay?YesNoDo you have a vehicle or source of transportation? *Choose OneYesNoHousehold IncomeWhat is your monthly household income amount?Do you receive CalWORKS benefits? *Please select an optionYesNoWhat is your current source of income? (Select all that apply) *EDD/ Unemployment Insurance BenefitsChild/Spousal SupportNon-Cash BenefitsEmployment IncomeSupplemental Security Income( SSI)Social security Disability Income (SSDI)VA Service-Connected Disability CompensationVA Non-Service-Connected Disability PensionPrivate Disability InsuranceWorkers CompensationTemporary Assistance for Needy Families (TANF)General Assistance (GA)Retirement Income from Social SecurityPension or retirement income form a former jobChild SupportAlimony or other spousal supportDo you receive any non-cash benefits (if none. select none)Choose OneSupplemental Nutrition Assistance Program (SNAP)TANF Child Care ServicesTemporary Rental AssistanceNoneCurrent or pending housing crisisWhat is the nature of your current housing "risk situation"? *Choose oneHomelessAt imminent risk of losing housingFleeing domestic violencestably housedWhat has triggered your current or pending housing crisis? (check all that apply) *Pending or recent eviction from rental housingSudden/significant increase in rentSudden/significant loss of household incomeUnanticipated financial incident or traumatic eventFleeing / attempting to flee domestic abuse,Dealing with chronic physical health issuesNone of the AbovePlease identify your current obstacles to achieving housing stability at this time? (check all that apply)No / limited income,Housing affordabilityFleeing / attempting to flee domestic abuseNone of the above applyAre you currently enrolled or approved for participation in any program that is or will be assisting you with monthly rent payments for a period of time? *choose oneYesNoDo you currently have household income, and/or a housing voucher in hand, sufficient to rent housing on your own, but face other barriers such as rental history, credit challenges, lack of funds for security deposit, etc.?Choose oneYesNoCurrent Living SituationPlease help us to further evaluate your current housing challenge(s) by responding to the following series of questions.What is the date (or month and year) that you originally moved into your current rental housing?Please enter the month, day and year you moved in. Correct Example 12/07/2023. Incorrect would be - 12-7-23What is your current monthly rent amount $?If behind on rent payments, how much do you currently owe in rent at this point in time?If you are not behind please place "0" as the amountAre you at imminent risk of losing your rental housing within the next 30 days?YesNoNot ApplicableDo you have the option to remain in your current rental housing if the "risk situation" can be resolved?YesNoN/ADo you have the personal financial means, current or pending, and/or other resources available to your household to help resolve your current housing "risk situation" with a limited amount of additional assistance? *Choose OneYesNoWhere might you go once you have to leave your current rental housing?If question dose not apply please respond with N/AIf you must leave your current living situation, do you have family, friends or other options available for a temporary place to stay until you can secure new housing on your own?YesNoNot ApplicableHousing HelpThere are a variety of housing and shelter resources available to assist families and/or individuals meeting specific characteristics. To help us try and identify all potential resources that might be available to assist you with your housing crisis, please respond to the following.Chronic Health Condition, Domestic Violence/Abuse Survivor, Single parent w/children under 18 *Chronic Health ConditionDomestic Violence/Abuse SurvivorSingle Parent w/children under 18NoneIs the health or disabling condition identified expected to be long continuing or of indefinite duration and substantially impede your and/or your household’s ability to live independently. *Choose OneYesNoNo ApplicableWould you be interested in considering a shared housing / cooperative living arrangement if such an option is available for your household?YesNoPlease provide any additional comments or information that you think might help with identifying referral options for your household.What agency and/or person referred you to the Rental Assistance Program?If an agency or caseworker referral please noteLandlord or Property Manager Information (rental assistance only and if you are still living in your home))fill this out for rental assistanceLandlord or Property Manager Contact NameName of the person we need to speak toLandlord or Property CompanyName of the company you pay your rent toEmail Address of property manager or landlordPhone of property manager or landlordProperty Manager AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeConsent *I understand that after I submit this request, that I will receive a consent form in my email that I must read and sign.CheckboxI understand this process can take 30-45 days.I understand that I must turn in all required documentation , if requested.I understand that this process is based on funding availability and I may not obtain funding unless it is available.Submit Request
