Motel to Home Referral Form

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To qualify for Motel to Home assistance, you must have at least one school age child between the ages of 4-18, have income, and currently be in a hotel for 30 days or more. If you meet these requirements you will be contacted and will need to provide required documents including at least 30 days of recent motel receipts.

Email *

First Name *

Last Name *

Phone Number

Preferred method of contact?
*

Phone call

Text

Required

Referred by:
*

Dunaire Elementary

Other:

Number of children in household *

Children's ages *

Number of adults in household (including yourself) *

Monthly income *

What is the name of the motel you and your family are currently staying at? *

How long have you been living in a motel?
*

What is the city and zip code of the motel? *

Housing Barriers (check all that apply)
*

Recent Eviction

Unpaid Eviction

Low credit score

Felony

Cannot afford application fees

None of the above

Other:

Required

I certify that I have the following:
*

at least 30 days of recent motel receipts

Income to pay market rate rent

A school aged child that lives with me

None of the above

Other:

Required

Other information

Send me a copy of my responses.

Submit

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