Housing Assistance Application

Name *

First Name

Last Name

Are you a Somerville resident? *

Yes

No

I don't know

Phone number *

(###)

###

####

Do you use email?

I use email

I have email, but don't check it often

I do not have an email address

Primary Language *

English

Spanish

Portuguese

Haitian Creole

Other

What is your household source of income?

Check all that apply for all household members

Employment

SSI/SSDI

TAFDC

Unemployment

Pension

Other

Do you owe rent?

Yes

No

I don't know

Have you been served a Notice to Quit? *

Yes

No

I don't know

Have you been served a Summons & Complaint? *

Yes

No

I don't know

Do you have a housing subsidy?

No

I don't know

Section 8

MRVP

Public Housing

Project-based Section 8 (came with the apartment)

What type of assistance are you in need of? *

Check all that apply

Rental Arrears

Start-Up Costs (first, last, security, brokers fee, movers)

Ongoing Rental Assistance

Utility Arrears

Applying for Public Benefits (IU, SNAP, TAFDC, MassHealth)

Housing Search (with Section 8)

Housing Search (without Section 8)

Applying for Affordable Housing

Have you received assistance from any of the following agencies in the last 12 months?

Check all that apply

Somerville Homeless Coalition

Just-A-Start

Office of Housing Stability (OHS)

Cambridge & Somerville Legal Services (CASLS)

De Novo

Elder Services