Rent Help & Security Deposits Request Form

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Funding requests can include security deposits, first month's rent, or rental arrears through this program, also referred to as the Prevention, Diversion, and Rehousing Program.

We receive far more requests for assistance from eligible families than we are able to provide. Although you may be eligible, our funding is limited. Please understand that requesting funds is not a guarantee that you will receive assistance. Please call 211 for additional resources.

To be eligible, you must:

(1) Have children 17 years of age or younger in your care.

(2) Be able to prove your ability to maintain the rent going forward.

(3) Have an eviction notice if requesting back rental funds.

(4) Need assistance for rent help or security deposit that does not exceed the amount we are willing, by policy, to provide to a given household.

After completing the below form, you will receive an email regarding eligibility within 2 weeks. You do not have to call to follow-up on your application. THANK YOU!

First Name *

Middle Name *

Last Name *

Date of Birth *

YYYY

Would you like to share your preferred pronouns?

Email Address *

Phone Number *

Gender

Male

Female

Non-binary

Other:

Clear selection

Race/Ethnicity *

Black/African American

White/Caucasian

Asian

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Multi-Race

Required

Ethnicity *

Hispanic or Latino

Non-Hispanic or Latino

Current Address (Including Town and Zip Code) *

How long have you lived at this address?

Place of employment and job title

Hours worked per week and pay per hour

Household Benefits and Amount received Monthly (SNAP, etc.) *

Partner/Spouse or other adult living in household

Second Adult Date of Birth

YYYY

Second Adult Race/Ethnicity

Black/African American

White/Caucasian

Asian

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Multi-Race

Second Adult Ethnicity

Hispanic or Latino

Non-Hispanic or Latino

Clear selection

Second Adult Place of employment and job title

Second Adult hours worked per week and pay per hour

Are there any other adults living in household? *

Yes

What is the source of your income? *

New York State Unemployment Insurance

EMPLOYMENT

SSI/SSDI

WORKERS COMPENSATION

Short Term Disability

Child Support

Other:

Required

Total household monthly income *

$0.00-$500/month

$500-$1500/month

$1500-$2000/month

$2000-$2500/month

$2500-$3000/month

$3000-$3500/month

$3500-$4000/month

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