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Apply Now for Rent/Utilities Assistance
Atomic Dev
2025-10-14T17:01:50-05:00
Apply For Rent/Utilities Assistance
Need help with rent or utility bills? Apply for assistance by filling out the form below, so we can help support you during this challenging time.
Fill out the form to apply:
Step
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This field is for validation purposes and should be left unchanged.
DIRECTIONS: Read question carefully. If you fail to fill out any part of this application truthfully, the application will be closed without review. If you do not live in our Primary Service Area and you select one of our service area zip codes, our system tells us your address is not in our area. We will consider this as providing false information and closing the case without review. If you do not live in our Primary Service area you should call 211 for an organization that services, your area. YOU SHOULD REVIEW EACH SECTION AFTER YOU HAVE FILLED IN FIELDS BEFORE GOING TO NEXT SECTION. DO NOT LEAVE OUT/OFF ANY INFORMATION THIS WILL CAUSE AN INACCURATE RESPONSE FROM US OR YOUR CASE TO BE CLOSED. ONCE YOU COMPLETE EACH SECTION AND CONTINUE YOU MAY NOT BE ABLE TO GO BACK TO CORRECT OR ADD/DELETE INFORMATION.
DO NOT APPLY MULTIPLE TIMES - YOUR FILE WILL BE CLOSED WITHOUT A RESPONSE. *****
By checking this box, A) I agree to receive texts from Now-Forward at the mobile number listed on your application. B) I have read the guidelines and basic requirements on the previous page, and I agree that completing the application does not guarantee assistance. C) I also agree that all information I provide is accurate and truthful and understand that if any information is not provided or is inaccurate my request for assistance will be closed without consideration.
(Required)
Yes
This field is hidden when viewing the form
Today Date
MM slash DD slash YYYY
Name (You must type in your full First, Middle and Last name)
(Required)
First
Middle
Last
Street Address: (ONLY)
(Required)
APT# (ONLY)
City
(Required)
State
Zip Code
(Required)
Telephone Phone
(Required)
Re-Enter Telephone
(Required)
For Verfication
Type of Phone:
Select
Cell
Work
Email Address:
(Required)
Re-Enter Email Address Again:
(Required)
for verification
Are you receiving? Leave blank if you are not receiving Medicare, Medicaid or Snap
Select
Medicaid
Medicare
SNAP
Photo ID# for applicant only
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Auto Formats
Age
Auto-calculates
Sex (M/F):
(Required)
Select One
FEMALE
MALE
Ethnicity:
(Required)
Select One
White
Black
Hispanic
Asian
Bi-Racial
Other
Unknown
Marital Status:
(Required)
Select One
Married
Single
Divorced
Separated
Widowed
Engaged
Common Law
Household Information
Total # of people living in household:
(Required)
Please enter a number greater than or equal to
1
.
Do you receive subsidized housing: DHA/Section 8
(Required)
Select
Yes
No
Where do you live:
(Required)
Select One
Apt/Condo
House
Duplex
Motel
Shelter
Trailer
Other
Apt/Condo/Motel name:
(Required)
Apt #
Landlord Name:
Landlord's Phone Number
(Required)
Auto Formats
Re-Enter Landlord's Phone Number
(Required)
Auto Formats - for verification
One month's rent is? *$
(Required)
Auto Formats
Move-in Date (Date U moved on to property)
(Required)
MM slash DD slash YYYY
Auto Formats
Years at Residence:
Auto calculates
Months(s)
Auto calculates
How many in household are on Medicaid?
(Required)
How many in household are on SNAP?
(Required)
(food stamps, use numbers)
Monthly Amount from SNAP $
Auto Formats
DO NOT LIST YOURSELF BELOW - ONLY ADDITIONAL INDIVIDUALS LIVING AT RESIDENCE WITH YOU
List Information for ALL OTHER ADULTS- Age 18 or over living in your household: failure to list the additional Adults (including First and Last Name) will cause your application to be declined.
YOU MUST INCLUDE ANYONE NOT ON LEASE
Total ADDITIONAL # of adults living in household:
(Required)
Please enter a number greater than or equal to
0
.
Adult 1 First Name
Adult 1 Middle Name
Adult 1 Last Name
Adult 1 Sex M/F
Select
Female
Male
Adult 1 Date of Birth
MM slash DD slash YYYY
Auto Formats
Adult 1 Age
Auto Calculates
Adult 1 Photo ID #
Adult 1 - Relationship to you
Select
Husband - Esposo
Wife - Esposa
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Father - Padre
Mother - Madre
Grandfather - Abuelo
Grandmother - Abuela
Father-in-law - Suegro
Mother-in-law - Suegra
Grandson - Nieto
Granddaughter - Nieta
Son-in-law - Yerno
Daughter-in-law - Hijastra
Brother-in-law - Cunado
Sister-in-law - Cunada
Nephew - Sobrino
Niece - Sobrina
Uncle - Tio
Aunt - Tia
Cousin - Primo
Fiance - Prometido
Boyfriend - Novio
Girlfriend - Novia
Friend - Amigo
Unknown
Is Adult 1 receiving?
Medicare
Medicaid
SNAP
Adult 2 First Name
Adult 2 Middle Name
Adult 2 Last Name
Adult 2 Sex M/F
Select
Female
Male
Adult 2 Date of Birth
MM slash DD slash YYYY
Auto Formats
Adult 2 Age
Auto Calculates
Adult 2 Photo ID #
Adult 2 - Relationship to you
Select
Husband - Esposo
Wife - Esposa
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Father - Padre
Mother - Madre
Grandfather - Abuelo
Grandmother - Abuela
Father-in-law - Suegro
Mother-in-law - Suegra
Grandson - Nieto
Granddaughter - Nieta
Son-in-law - Yerno
Daughter-in-law - Hijastra
Brother-in-law - Cunado
Sister-in-law - Cunada
Nephew - Sobrino
Niece - Sobrina
Uncle - Tio
Aunt - Tia
Cousin - Primo
Fiance - Prometido
Boyfriend - Novio
Girlfriend - Novia
Friend - Amigo
Unknown
Is Adult 2 receiving?
Medicare
Medicaid
SNAP
Adult 3 First Name
Adult 3 Middle Name
Adult 3 Last Name
Adult 3 Sex M/F
Select
Female
Male
Adult 3 Date of Birth
MM slash DD slash YYYY
Auto Formats
Adult 3 Age
Auto Calculates
Adult 3 Photo ID #
Adult 3 - Relationship to you
Select
Husband - Esposo
Wife - Esposa
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Father - Padre
Mother - Madre
Grandfather - Abuelo
Grandmother - Abuela
Father-in-law - Suegro
Mother-in-law - Suegra
Grandson - Nieto
Granddaughter - Nieta
Son-in-law - Yerno
Daughter-in-law - Hijastra
Brother-in-law - Cunado
Sister-in-law - Cunada
Nephew - Sobrino
Niece - Sobrina
Uncle - Tio
Aunt - Tia
Cousin - Primo
Fiance - Prometido
Boyfriend - Novio
Girlfriend - Novia
Friend - Amigo
Unknown
Is Adult 3 receiving?
Medicare
Medicaid
SNAP
Adult 4 First Name
Adult 4 Middle Name
Adult 4 Last Name
Adult 4 Sex M/F
Select
Female
Male
Adult 4 Date of Birth
MM slash DD slash YYYY
Auto Formats
Adult 4 Age
Auto Calculates
Adult 4 Photo ID #
Adult 4 - Relationship to you
Select
Husband - Esposo
Wife - Esposa
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Father - Padre
Mother - Madre
Grandfather - Abuelo
Grandmother - Abuela
Father-in-law - Suegro
Mother-in-law - Suegra
Grandson - Nieto
Granddaughter - Nieta
Son-in-law - Yerno
Daughter-in-law - Hijastra
Brother-in-law - Cunado
Sister-in-law - Cunada
Nephew - Sobrino
Niece - Sobrina
Uncle - Tio
Aunt - Tia
Cousin - Primo
Fiance - Prometido
Boyfriend - Novio
Girlfriend - Novia
Friend - Amigo
Unknown
Is Adult 4 receiving?
Medicare
Medicaid
SNAP
List Information for ALL CHILDREN- Age 17 or younger living in your household: failure to list ALL CHILDREN (including First and Last Name) will cause your application to be declined.
YOU MUST INCLUDE ANYONE NOT ON LEASE
Total # of children living in household:
(Required)
Please enter a number greater than or equal to
0
.
Child 1 First Name
Child 1 Middle Name
Child 1 Last Name
Child 1 Sex M/F
Select
Female
Male
Child 1 Date of Birth
MM slash DD slash YYYY
Auto Formats
Child 1 Age
Auto Calculates
This field is hidden when viewing the form
If younger than a year use # of Month(s)
Child 1 - Relationship to you
Select
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Grandson - Nieto
Granddaughter - Nieta
Nephew - Sobrino
Niece - Sobrina
Cousin - Primo
Unknown
Is Child 1 receiving?
Medicaid
SNAP
Child 2 First and Last Name
Child 2 Middle Name
Child 2 Last Name
Child 2 Date of Birth
MM slash DD slash YYYY
Auto Formats
Child 2 Age
Auto Calculates
Child 2 Sex M/F
Select
Female
Male
This field is hidden when viewing the form
If younger than a year use # of Month(s)
Child 2 - Relationship to you
Select
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Grandson - Nieto
Granddaughter - Nieta
Nephew - Sobrino
Niece - Sobrina
Cousin - Primo
Unknown
Is Child 2 receiving?
Medicaid
SNAP
Child 3 First and Last Name
Child 3 Last Name
Child 3 Last Name
Child 3 Sex M/F
Select
Female
Male
Child 3 Date of Birth
MM slash DD slash YYYY
Auto Formats
Child 3 Age
Auto Calculates
This field is hidden when viewing the form
If younger than a year use # of Month(s)
Child 3 - Relationship to you
Select
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Grandson - Nieto
Granddaughter - Nieta
Nephew - Sobrino
Niece - Sobrina
Cousin - Primo
Unknown
Is Child 3 receiving?
Medicaid
SNAP
Child 4 First Name
Child 4 Middle Name
Child 4 Last Name
Child 4 Sex M/F
Select
Female
Male
Child 4 Date of Birth
MM slash DD slash YYYY
Auto Formats
Child 4 Age
Auto Calculates
This field is hidden when viewing the form
If younger than a year use # of Month(s)
Child 4 - Relationship to you
Select
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Grandson - Nieto
Granddaughter - Nieta
Nephew - Sobrino
Niece - Sobrina
Cousin - Primo
Unknown
Is Child 4 receiving?
Medicaid
SNAP
Child 5 First Name
Child 5 Middle Name
Child 5 Last Name
Child 5 Sex M/F
Select
Female
Male
Child 5 Date of Birth
MM slash DD slash YYYY
Auto Formats
Child 5 Age
Auto Calculates
This field is hidden when viewing the form
If younger than a year use # of Month(s)
Child 5 - Relationship to you
Select
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Grandson - Nieto
Granddaughter - Nieta
Nephew - Sobrino
Niece - Sobrina
Cousin - Primo
Unknown
Is Child 5 receiving?
Medicaid
SNAP
Child 6 First Name
Child 6 Middle Name
Child 6 Last Name
Child 6 Sex M/F
Select
Female
Male
Child 6 Date of Birth
MM slash DD slash YYYY
Auto Formats
Child 6 Age
Auto Calculates
This field is hidden when viewing the form
If younger than a year use # of Month(s)
Child 6 - Relationship to you
Select
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Grandson - Nieto
Granddaughter - Nieta
Nephew - Sobrino
Niece - Sobrina
Cousin - Primo
Unknown
Is Child 6 receiving?
Medicaid
SNAP
Child 7 First Name
Child 7 Middle Name
Child 7 Last Name
Child 7 Sex M/F
Select
Female
Male
Child 7 Date of Birth
MM slash DD slash YYYY
Auto Formats
Child 7 Age
Auto Calculates
This field is hidden when viewing the form
If younger than a year use # of Month(s)
Child 7 - Relationship to you
Select
Son - Hijo
Daughter - Hija
Brother - Hermano
Sister - Hermana
Grandson - Nieto
Granddaughter - Nieta
Nephew - Sobrino
Niece - Sobrina
Cousin - Primo
Unknown
Is Child 7 receiving?
Medicaid
SNAP
HOUSEHOLD INCOME INFORMATION
You will be required to provide proof of your income and all working individuals in the residence. You will need to send 2 paystubs for your current employer(s). We require current consecutive paystubs. EMPLOYERS DO NOT COUNT IF YOU ARE NO LONGER EMPLOYED AT THE COMPANY.
Source of Your Income?
(Required)
Select One
Current Job
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
Your MONTHLY Net Income $
(Required)
(add your take home amount for all your paychecks from this source for the last 30 days)
Total HOUSEHOLD Monthly Net Income?*$
(Required)
(Auto calculating field)
You must have CURRENT income to receive NOW-FORWARD'S financial assistance
Applicant's Income
You must have current verifiable income. If you do not work at the employer on the day that you apply, then that employer does not count. We do accept SSI, SSDI and Unemployment as income. You must be working 35-40 hours a week.
Applicant's Current Employer's Name (Main Income):
(Required)
Phone - you must provide if you are working for a company.
This field auto formats
APPLICANTS TIME ON JOB
Length of Time in Numbers Only.
(Required)
Choose the time frame (Days, Weeks, Months, Years):*
(Required)
Select
Days
Weeks
Months
Years
This field is hidden when viewing the form
Number
APPLICANT'S ADDITIONAL INCOME
Use the following income section to report your additional income: (child support, extra job, any income not listed as your main income)
Source 2 of Applicants Additional Income.
Select
Job 2
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
Applicants Monthly Income from 2nd Source? $
(take home amount for 30 days from this source)
Source 3 of Applicants Additional Income.
Select
Job 3
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
3rd Sources Monthly Income? $
(take home amount for 30 days from this source)
Monthly amounts from SNAP
(take home amount)
ADDITIONAL PERSON'S INCOME - THIS INCLUDES ALL WORKING AGE INDIVIDUALS LIVING AT THIS ADDRESS
You are required to complete this information for Roommates, husbands/wife, boyfriend/girlfriend or any other individual living at the address listed on the application that is working.
Is there additional income in the household?
(Required)
Select One
No
Yes
Source of Additional Person's Income (Second Persons Main Income)?
(Required)
Select One
Additional Persons Job
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
Additional Person's MONTHLY Net Income $ from this Source:
(Required)
(add your take home amount for all your paychecks from this source for the last 30 days)
Additional Person's Current Employer's Name:
(Required)
Additional Person's Employers Phone # (If they work for a company you must provide this information): (this field will autoformat)
Additional Person's Time on Job? (example: 6 weeks, 7 months, years)*
Length of Time in Numbers Only.
(Required)
Choose the time frame (Days, Weeks, Months, Years):*
(Required)
Select
Days
Weeks
Months
Years
This field is hidden when viewing the form
Number
ADDITIONAL PERSON'S ADDITIONAL INCOME
Use the following income section to report your additional income: (child support, extra job, any income not listed as your main income)
Additional Person's 2nd Source of Income
Select
Additional Persons Job 2
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
Additional Person's Monthly Income from 2nd Source? $
(take home amount for 30 days from this source)
Additional Person's 3rd Source of Income
Select
Additional Persons Job 3
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
Additional Person's Monthly Income from 3rd Source? $
(take home amount for 30 days from this source)
FINANCIAL ASSISTANCE NEEDED
What kind of help do you need?
(Required)
Select One
Rent
Utilities
Rent and Utilities
Amount you owe for Rent *$
(Required)
Amount you owe for Utilities $
(Required)
Brief explanation - the cause of the unforeseen emergency. If you fail to provide cause for your emergency, and documented proof. Your request will be closed.
(Required)
A RESPONSE WILL BE EMAILED TO YOU WITHIN 2-4 DAYS ONCE YOU SUBMIT.
IF YOU FAIL TO READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS YOUR APPLICATION CAN BE CLOSED WITHOUT RESPONSE.
Proof of Current Income
YOU MUST HAVE VERIFIABLE CURRENT INCOME. (Current employer only - past employers do not count) attach current paystubs, dates and names must be visible and document must be readable. DO NOT SEND FILES BIGGER THAN OUR MAX FILE SIZE. THIS WILL CAUSE THE ATTACHMENTS TO BE CORRUPTED OR STOP APPLICATION FROM BEING SUBMITTED.
Current Employer - Most Recent Paystub Received - PAST EMPLOYMENT DOES NOT COUNT
Accepted file types: jpg, png, pdf, doc, Max. file size: 50 MB.
Current Employer- Paystub Received right before the one you attached to left.
Accepted file types: jpg, png, pdf, doc, Max. file size: 50 MB.
Other income is proof of any of the following: additional jobs, Unemployment payments, SSI/SSDI, child support, Retirement payments, spouses or roommate's paystubs, etc. - DO NOT ATTACH OR EMAIL BLANK PAGES.
Proof of any Other Type of Income
Accepted file types: jpg, png, pdf, doc, Max. file size: 50 MB.
Utility Bill - NO MORE THAN 2 PAGES
Accepted file types: jpg, png, pdf, doc, Max. file size: 50 MB.
If you send your lease agreement, only send the page that tells the monthly rent and who resides in the home, as well as the move in date. DO NOT ATTACH OR EMAIL COMPLETE LEASES. DO NOT EMAIL BLANK PAGES OF ANY OF THE DOCUMENTS. THIS SHOULD BE NO MORE THAN 1 PAGE.
Lease - DO NOT SEND MORE THAN ONE PAGE. REQUIRED PAGE IS THE ONE THAT SHOWS THE MOVE IN DATE, ADDRESS, OCCUPANTS OF THE HOUSEHOLD.
Accepted file types: jpg, png, pdf, doc, Max. file size: 20 MB.
YOU ONLY NEED TO CLICK ONCE TO SUBMIT APPLICATION. YOU WILL RECEIVE AN EMAIL AND A POP-UP MESSAGE WHEN THE APPLICATION TRANSMITS.
You must have income to receive NOW-FORWARD'S financial assistance
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