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Apply Now for Rent/Utilities Assistance
Atomic Dev
2025-02-05T16:10:38-06:00
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
1
of
13
7%
Read question carefully. If you fail to fill out any part of this application truthfully, it may be closed without review.
DO NOT APPLY MULTIPLE TIMES - YOUR FILE WILL BE CLOSED WITHOUT A RESPONSE.
I have read the basic requirements and understand completing the application does not guarantee assistance.
(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 and last name)
(Required)
First
Middle
Last
Street Address
(Required)
Apartment #
City
(Required)
Zip Code (Your zip code not listed, you are outside our Primary Service Area, call 211)
(Required)
Select One
75001
75023
75204
75205
75209
75115
75116
75219
75220
75225
75229
75230
75231
75234
75235
75240
75243
75244
75247
75248
75251
75252
75254
75287
99999(Homeless)
You selected a ZIP code outside of our service area, please call 211 to get info on an organization in their area to help them.)
Telephone Phone
(Required)
Re-Enter Telephone
(Required)
For Verfication
Type of Phone:
Select
Cell
Work
Email Address:
(Required)
Re-Enter Email Address Again:
(Required)
Are you receiving?
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
F
M
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
One month's rent is? *$
(Required)
Auto Formats
Move-in Date
(Required)
MM slash DD slash YYYY
Auto Formats
Years at Residence:
Auto calculates
Months(s)
Auto calculates
How many are on Medicaid?
(Required)
How many are on SNAP
(Required)
(food stamps, use numbers)
Monthly Amount from SNAP $
Auto Formats
DO NOT LIST YOURSELF BELOW - ANYONE ELSE LIVING AT RESIDENCE MUST BE LISTED
List Information regarding ALL OTHER ADULTS Age 18 or over living in your household: failure to list Adults or children may have your application declined. Date of Birth will autoformat.
Total additional # of adults living in household:
(Required)
Please enter a number greater than or equal to
0
.
Adult 1 First and Last Name
Adult 1 Sex M/F
Select
Female
Male
Adult 1 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Adult 1 Photo ID #
Adult 1 Age
Auto Calculates
Is Adult 1 receiving?
Medicare
Medicaid
SNAP
Adult 2 First and Last Name
Adult 2 Sex M/F
Select
Female
Male
Adult 2 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Adult 2 Photo ID #
Adult 2 Age
Auto Calculates
Is Adult 2 receiving?
Medicare
Medicaid
SNAP
Adult 3 First and Last Name
Adult 3 Sex M/F
Select
Female
Male
Adult 3 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Adult 3 Photo ID #
Adult 3 Age
Auto Calculates
Is Adult 3 receiving?
Medicare
Medicaid
SNAP
Adult 4 First and Last Name
Adult 4 Sex M/F
Select
Female
Male
Adult 4 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Adult 4 Photo ID #
Adult 4 Age
Auto Calculates
Is Adult 4 receiving?
Medicare
Medicaid
SNAP
List Information for ALL CHILDREN under 18 living in your household
Total # of children living in household:
(Required)
Please enter a number greater than or equal to
0
.
Child 1 First and Last Name
Child 1 Sex M/F
Select
Female
Male
Child 1 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Child 1 Age
Auto Calculates
If younger than a year use # of Month(s)
Is Child 1 receiving?
Medicare
Medicaid
SNAP
Child 2 First and Last Name
Child 2 Sex M/F
Select
Female
Male
Child 2 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Child 2 Age
Auto Calculates
If younger than a year use # of Month(s)
Is Child 2 receiving?
Medicare
Medicaid
SNAP
Child 3 First and Last Name
Child 3 Sex M/F
Select
Female
Male
Child 3 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Child 3 Age
Auto Calculates
If younger than a year use # of Month(s)
Is Child 3 receiving?
Medicare
Medicaid
SNAP
Child 4 First and Last Name
Child 4 Sex M/F
Select
Female
Male
Child 4 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Child 4 Age
Auto Calculates
If younger than a year use # of Month(s)
Is Child 4 receiving?
Medicare
Medicaid
SNAP
Child 5 First and Last Name
Child 5 Sex M/F
Select
Female
Male
Child 5 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Child 5 Age
Auto Calculates
If younger than a year use # of Month(s)
Is Child 5 receiving?
Medicare
Medicaid
SNAP
Child 6 First and Last Name
Child 6 Sex M/F
Select
Female
Male
Child 6 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Child 6 Age
Auto Calculates
If younger than a year use # of Month(s)
Is Child 6 receiving?
Medicare
Medicaid
SNAP
Child 7 First and Last Name
Child 7 Sex M/F
Select
Female
Male
Child 7 Date of Birth
MM slash DD slash YYYY
Auto Formats
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
Child 7 Age
Auto Calculates
If younger than a year use # of Month(s)
Is Child 7 receiving?
Medicare
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 that 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)
(take home amount)
Total HOUSEHOLD Monthly Net Income?*$
(Required)
(Auto calculating field)
You must have CURRENT income to receive NDSM financial assistance
Your Current Employer's Name:
(Required)
Phone
This field auto formats
Your Current Employment Length or length you are receiving your form of income? (example: 6 weeks, 7 months, years) only enter #'s in this box*
(Required)
Days, Weeks, Months, Years:*
(Required)
Select
Days
Weeks
Months
Years
Other Monthly Income? $
(take home amount)
Select One
Select
Job 2
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
Other Monthly Income? $
(take home amount)
Select One
Select
Job 3
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
Monthly amounts from SNAP
(take home amount)
ADDITIONAL PERSON'S INCOME
You are required to complete this information for Room mates, husbands/wife, boyfriend/girlfriend or any other individual living at the address listed on the application.
Is there additional income in the household?
(Required)
Select One
No
Yes
Source of Additional Person's 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 $
(Required)
(take home amount)
Additional Person's Current Employer's Name:
(Required)
Additional Person's Employers Phone: (this field will autoformat)
(Required)
Additional Person's Current Employment Length? (example: 6 weeks, 7 months, years)*
(Required)
Days, Weeks, Months, Years:*
(Required)
Select
Days
Weeks
Months
Years
Additional Person's Other Monthly Income? $
(take home amount)
Select One
Select
Additional Persons Job 2
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
Additional Person's Other Monthly Income? $
(take home amount)
Select One
Select
Additional Persons Job 3
Unemployment Compensation
SS Retirement
SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
Other
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 of why you need this help? (Reason that caused you to be behind) If you fail to tell us reason for your emergency then your request maybe 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.
Current Employer - Most Recent Paystub Received
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 email blank pages of documents.
Proof of any Other Type of Income
Accepted file types: jpg, png, pdf, doc, Max. file size: 50 MB.
Utility Bill
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 lease. - Do not email blank pages of documents.
Lease
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 pop up message when it transmits.
You must have income to receive NDSM financial assistance
Comments
This field is for validation purposes and should be left unchanged.
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