Tenant Application Please answer all questions unless indicated otherwise. * indicates required information.Housing informationIs your primary residence a rental apartment located in Rhode Island?*YesNoCurrently unhousedAre you currently receiving rental assistance?*YesNoHow many bedrooms are in your apartment?*Studio (0)123456+What is your monthly rent payment?*Which of the following best describes your situation? Please select one.*I fell behind on my rent, but can pay going forward.I fell behind on my rent and don’t know how I will pay next month, either.I am not behind on my rent, but my landlord wants to evict me for a different reason.Please explain.:What is the total amount of rent you owe since March 1, 2020?*For each month listed, please indicate the amount of rent you owe: MarchAprilMayJuneJulyAugustSeptemberOctoberHas your landlord served you with an eviction notice?*YesNoNot SureHave you ever been evicted before? (This question is for research only and will not impact your application.)*YesNoNot SureHave you filed any housing code complaints against your landlord that you are still waiting to have resolved?*YesNoHas your landlord sent you a demand notice for late rent?*Yes, I received a five-day demand notice for nonpayment of rent.No, I haven’t received any demand notice.Have you received a summons for an eviction hearing? If so, when is your court date?*YesNoCourt hearing dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you received assistance through the Housing Help RI program?*Yes, I applied and received assistance.I applied but was found ineligible.I applied and am still waiting.No, I did not apply to Housing Help RI.Applicant informationName* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email Phone*Race*American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteI prefer not to answerEthnicity*Hispanic or LatinoNot Hispanic or LatinoI prefer not to answerGender*FemaleMaleHow many total people live in your household? Please list below all members of the household other than yourself.NameDate of birth Disability status*One or more household member(s) is experiencing a disability.No household member is experiencing a disability.I prefer not to answer.Are you represented by an attorney?*YesNoIf yes, please enter your attorney's contact information.Income informationHave you experienced financial hardship due to the COVID-19 emergency?*YesNoWhat was the reason for your financial hardship? Please select an option from the dropdown menu.*Laid-offJob terminatedPlace of employment closedLoss of work hours, wages and tips, or business incomeCannot return to work due to lack of childcareOther (please explain)Please explain the connection between your financial hardship and the COVID-19 emergency.*What is your household’s current approximate total monthly income now? Please include income from all household members.*Please upload supporting documents that show your household’s total monthly income, including income from all members. Please make sure the documents are recent. * Drop files here or Accepted file types: csv, doc, docx, pdf, gif, jpg, png, svg, tif, tiff, xls, xlsx. If electronic files are not available, you can take a picture of the documents with your phone or other device and upload the photos. If you're unable to upload your files they may be mailed to: United Way of Rhode Island c/o SHHP Project Manager 50 Valley St. Providence, RI 02909 Select up to 10 files to attach. Preferred documents: Bank statements; Pay stubs or other documents from an employer; Awards letters for Social Security, unemployment insurance, or other state or federal benefits Other evidence of self-employment or business income If applicable, please upload your eviction summons or complaint.Accepted file types: jpeg, jpg, gif, png, pdf.Please upload your current lease agreement or other proof of residence such as a utility bill.Accepted file types: jpeg, jpg, pdf, gif, png.Landlord informationHave you spoken with your landlord or property manager about participating in the Safe Harbor program?*YesNo, but I can speak to them about my applicationNo, and I need help speaking with them about my applicationPlease provide the best contact information for the landlord or property manager.Company name (if applicable)Name First Last Address Street Address City State / Province / Region ZIP / Postal Code Email PhonePhoneThis field is for validation purposes and should be left unchanged.