Question title

Provide the tenant contact information.

Question title

Tell us how to reach the landlord:

The following questions pertain to the tenant and should only be completed by the tenant.

Question title

What is your race/ethnicity?

White
Black or African-American
Hispanic, Latino, or Spanish
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
I prefer not to answer
Closed to responses

Question title

What is your gender?

Male
Female
Transgender
Do not identify as male, female, or transgender
Prefer not to answer
Closed to responses

Question title

Please provide the Social Security Number and Date of Birth for the primary applicant.

Closed to responses

Question title

Are you:

None of the above
89%
disabled
10%
A veteran
3%
Closed to responses | 741 Responses

Question title

How many adults live in the household?

Closed to responses

Question title

How many total people live in the household?

1
32%
2
26%
3
18%
4
12%
5
7%
6
4%
7
1%
8
0%
9
0%
10
0%
Closed to responses | 814 Responses

Question title

Please provide household member information:

You will use the following format and repeat until all members are listed:

First Name Last Name

Gender

Date of Birth

Member Relationship to Primary Applicant

(Repeat if necessary, skip if single)

Closed for Comments

Question title

Tell us what has caused you to need rental assistance?

I contracted COVID-19 which impacted my ability to work
COVID -19 impacted my place of employment (I lost my job or my hours/salary)
I currently have health issues that prevent me from working
I have applied for or received unemployment assistance in the last 12 months
Childcare options have been impacted due to COVID-19
Other: please describe
Closed to responses

Question title

Please indicate all sources of income for the household, even unrelated individuals.

Employment
55%
none
22%
SSI/SSD
10%
Unemployment
7%
child support
7%
other
6%
self-employment
5%
social security
5%
disability
4%
Pension
0%
Closed to responses | 631 Responses

Question title

Please provide your household income including any gross salary, business net income, rental real estate income, social security, overtime, tips, bonuses, interest & dividends, pensions, unemployment, worker's comp, alimony, child support, welfare payments, TANF, other income

Provide the most recent income in the following format:

weekly

bi-weekly

monthly

If you don't have income, put N/A

Closed for Comments

Question title

Please provide your employer name, address, and phone number:
If you are unemployed, retired, or disabled, list N/A below.

Closed for Comments

Question title

Have you applied for assistance from any of the following agencies in the past 12 months ? (Application does not mean automatic disqualification).

Other
41%
Community Action Partnership (CAP) of Greater Dayton)
29%
Catholic Soclal Services
11%
Homefull
8%
State of Ohio
8%
Goodwill Easter Services
7%
Salvation Army
5%
Greater Dayton Apartment Association
2%
Closed to responses | 213 Responses

Question title

Have you received PRC (Prevention/Retention/Contention) since July 1, 2020?

No
97%
Yes
2%
Awarded, not received
1%
Closed to responses | 722 Responses

Question title

Has a 3-day notice or eviction been filed against you?

Yes, a 3-day notice
Yes, an Eviction filing
No, but I'm behind in my rent
No, but I can't pay my rent this month
Closed to responses

Question title

Have you filed eviction declarations?

An eviction declaration is a form you complete and give to your landlord stating you aren't eligible to be evicted and why. You can see a sample here:

https://www.cdc.gov/coronavirus/2019-ncov/communication/EvictionProtectDeclare_508.pdf

No
96%
Yes
4%
Closed to responses | 353 Responses

Question title

Have you ever received rental assistance of any kind?

No
72%
Yes
28%
Closed to responses | 355 Responses

Question title

Have you applied to any other agency for funding for the rent and/or utilities for the last 12 months or the future 3 months?

No
79%
Yes
17%
Im not sure
5%
Closed to responses | 222 Responses

Question title

Any important information you want staff to know about? (Such as plans to move out, recent job loss, utilities shut off, etc?)

Tell us more:
100%
Closed to responses | 106 Responses