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.

Has your household been impacted by COVID19?

Yes

Phone Number

Are you currently receiving services from a homeless service provider?

Yes

Please select a homeless service provider below.

Social Worker/Case Manager Email

How many household members including yourself?

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 is your monthly rent?

Are you behind on your rent?

Yes

How many months are you behind?

What months do you owe?

Do you have a tenancy summons or lockout notice?

Yes

Please be advised due to current federal and state eviction moratorium we are unable to proceed with your application, you may reapply at a later date upon the lifting of the state’s eviction moratorium. Please visit nj211.org for further assistance.

Do you have a tenancy summons or lockout notice?

Yes

Are you living in an a place not meant for human habitation, emergency shelter , or transitional housing? If yes when did you become homeless?

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

Phone Number

What is your monthly rent?

Have you or a family member been impacted by Covid-19 If so, please select the situation which most closely describes your situation

Are you homeless?

Household member(s) workplace closure or reduced hours resulting from employer economic impacts of coronavirus

Household member(s) notification of job loss/termination or furlough from employer

Diagnosed with coronavirus or caring for a household or family member who is sick with coronavirus

Extraordinary out-of-pocket childcare expenses due to school closures, medical expenses or healthcare expenditures stemming from coronavirus infection of the tenant or a member of the tenant’s household who is ill with coronavirus

Other please explain

What type of assistance do you need?

Assistance with back rent

Security Deposit

Rental Assistance

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)

Are you living in an 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

How long? Are they asking you to leave the residence?

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.