[Housing Authority of Bergen County] Homeless Prevention Application

Homeless Prevention Application

Are you a Bergen County Resident?

Yes

Ineligible due to not being a Bergen County Resident.

Do you receive assistance for your rent? (Such as Section 8 rental assistance or other housing subsidy)

Yes

Ineligible due to subsidy assistance.

Are you currently receiving services from a homeless service provider?

Yes

Please select a homeless service provider below.

Social Worker/Case Manager Email

Social Worker/Case Manager Phone Number

Are you a registered sex offender?

Yes

Ineligible due to sex offender status.

What type of assistance do you need?

Assistance with Back Rent

Security Deposit

Rental Assistance

How many household members including yourself?

Are you behind on your rent?

Yes

How many months are you behind?

What is your gross annual income before taxes? Please include income for all family members over the age of 18. (Include all adult members income sources)

What months do you owe?

Do you have a tenancy summons or lockout notice?

Yes

Are you living in a place not meant for human habitation, emergency shelter , or transitional housing?

Yes

When did you become homeless?

Are you temporarily living with friends or family?

Yes

Please be advised, you are not at risk of homelessness, you may reapply at a later date. Please visit habcnj.org/apply for other housing opportunities.

How long have you been living w/ friends or family?

Are they asking you to leave the residence?

Yes

What is your monthly rent?

How many household members including yourself?

What is your gross annual income before taxes? Please include income for all family members over the age of 18. (Include all adult members income sources)

Phone Number

Please be advised, you are not at risk of homelessness, you may reapply at a later date. Please visit habcnj.org/apply for other housing opportunities.

Confirmation

You will be provided with a Confirmation upon submission.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.