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Rapid Response Application
For Somerville Residents Only
Please complete this application only if you are in housing and need assistance with paying your rent (including rental arrears) or utilities (must have a shut off notice). After submitting your application, a staff member will reach out to you.
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* Indicates required question
Applicant's Name
*
Your answer
If working with a case manager who will be assisting in your application, please list their name, agency and contact information.
Your answer
Current Address
*
Your answer
Phone Number
Your answer
Email Address
Your answer
Preferred language (English, Spanish, Portuguese, etc.)
*
Your answer
Priority Status- please select the items below that apply to your household. This helps our agency prioritize applications. If one of the below categories is true, your case will be prioritized.
I have received a Summons & Complaint for rental arrears
I have received a Notice to Quit for rental arrears
Someone in my household is undocumented
What kind of agreement do you have with your landlord?
*
Current lease agreement
Expired lease agreement that rolled over to a month-to-month agreement
Expired lease agreement that landlord refuses to renew
Verbal agreement with landlord
I sublet from a tenant- Landlord knows I live here
I sublet from a tenant- Landlord does not know I live here
I don't know
How much is your monthly rent?
Your answer
Do you have a housing subsidy?
No
Unsure
Section 8
Public or Elderly Housing
MRVP or AHVP subsidy
Project based Section 8 (came with the apartment)
Other subsidy
Clear selection
For
ALL individuals living in the unit
, please list (1) Full Name (2) Relationship to the head of household (3) Date of Birth (4) Age (5) Sex
*
Your answer
Are there any other individuals living with you in your unit that are not part of your household? (Roommates, friends, other family members, etc.)
*
Yes
No
Is a change of household composition expected? If yes, what type of change and when?
*
Your answer
What type of assistance are you in need of? (Check all that apply)
*
Rental Arrears
Ongoing Rental Assistance
Utility Arrears
Mortgage Assistance
Other:
Required
How much assistance do you need? (dollar amount)
*
Your answer
Which of the following explain any COVID-related aspects of your need for assistance:
*
My need for assistance is not COVID-related
I lost employment due to COVID
I work fewer hours and earn less money due to COVID
My household's expenses have increased due to COVID
Other persons in my household lost all or part of their income due to COVID
Other persons who were helping to pay the rent moved out due to COVID
Other:
If you owe rental arrears or utility arrears, why have you been unable to pay?
Your answer
If you owe rental arrears, how were you able to pay your rent previously before the arrears began accruing?
*
Your answer
Will you be able to pay for your expenses after assistance? If yes, please explain how. If no, what is your plan for retaining your housing after assistance?
*
Your answer
Check all that apply to your household:
*
A member of the household is employed
A member of the household expects to work in the next 12 months
A member of the household works for someone who pays them in cash
A member of the household receives or expects to receive child support
A member of the household receivers or expects to receive alimony payments
A member of the household is not receiving child support or alimony payments they are entitled to
A member of the household receives unemployment benefits
A member of the household receives or expects to receive welfare payments (SSI, TAFDC, EAEDC etc)
A member of the household receives or expects to receive Social Security benefits
A member of the household receives income from a pension or annuity
A member of the household receives regular financial contributions from someone outside of the household (ex: family, friends, agencies)
A member of the household receives income from assets such as stocks, bonds, or interest from a bank account
A member of the household expects to receive an earned income tax credit
A member of the household owns a home or other property
A member of the household has sold or given away property within the last two years
None of the above
Required
If anyone in your household receives wages from employment, please list their name and amount received monthly,
*
Your answer
If anyone in your household receives SSI or SSDI, please list their name and amount received monthly,
*
Your answer
If anyone in your household receives unemployment, please list their name and amount received monthly,
*
Your answer
If anyone in your household receives EAEDC or TAFDC, please list their name and amount received monthly,
*
Your answer
If anyone in your household receives child support, please list their name, amount received and how often.
*
Your answer
Please list any other household income.
Your answer
Does anyone your household have a bank account? If so, please report the following for each account: 1) the type of account 2) the approximate current cash value in the account 3) any interest rates that may apply (if known)
*
Your answer
If applicable, please provide us with contact information for your landlord (name, address, email address and phone number)
Your answer
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