ADRC APPLICATION – Emergency Rental Assitance Program

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Eligibility
ADRC Support

Emergency Rental Assistance Program

Eligibility
ADRC Support

Emergency Rental Assistance Program

ADRC Application 2025.

The Aging and Disability Resource Center (ADRC) connects older adults, individuals with disabilities, and their caregivers to vital resources and services. Whether you’re seeking assistance with housing, healthcare, or long-term care planning, ADRC is here to help.

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Applicants Information - Step 1 of 4

Full Name *

First

Middle

Last

Mother's Maiden Name *

Phone *

Email *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number *

Income

What currently described your employment status?

Self-employed
Employed
Unemployed
Retired

What is your current occupation? *

What was your gross annual income in 2023 *

How many people live in your household including you? *

A household is everyone living in your home, including you.

What was household’s annual income in 2023 *

Your household annual income is the total of what everyone in your household over age 18 earned in 2023. Total should include:

Wages
Salaries
Unemployment benefits
Pensions
Supplemental Security Income (SSI)
Rental income

Are you disabled? *

Yes
No

Do you have any disabilities or medical conditions that may impact your ability to access or maintain stable housing?

Are you currently receiving SSI or any other government benefits for financial support? *

Yes
No

Risk of housing instability or homelessness

Have you received a past due rent, past due utility, eviction notice, or other official notice? *

Yes
No

Notices or paperwork may include:

Past due rent notice
Past due or shut-off notice from your utility company
Official notice that you have to leave your residence (e.g., eviction notice, "notice to quit," or "pay or quit notice")
Eviction court paperwork with a hearing date

Eviction court hearing date (optional)

Residence and Monthly Rent

All field are required unless stated otherwise noted.

Do you have a utility bill that shows your name and rental address? *

Yes
No

This document would be used for further verification upon approving your rental assistance.

Do you have documents that show your past rent payments? *

Yes
No

This might include receipts, bank statements, check stubs, screenshots of electronic payments, or other types of documentation.

Attestation *

I attest that this information provided for household income is correct and complete to the best of my knowledge.

Rent Assitance

All field are required unless stated otherwise noted.

Did you file a tax return last year or in recent years? *

Yes
No

Did you receive assistance from a state or federal program to cover rent during the months for which you are requesting ERA assistance? *

Yes
No

NOTE: For confirmation of participation in any federal, state, or local government assistance program does not negatively impact your eligibility but instead may expedite your application.

How many months did you received assistance in 2023 *

Enter the amount of assistance you received in 2023 *

Are you seeking assistance with your rent? *

Yes
No

What is your current rent per month? *

Are you past due on rent? *

Yes
No

You may receive a total of 12 months of assistance for overdue rent.

How many months have you been past due on rent in 2023? *

Did you make any partial payments? *

Yes
No

Enter the total amount of partial fees you have paid *

Do you pay any fees? *

Yes
No

Fees may include late fees, legal court fees, and other fees related to your housing.

Total fees due today *

Do you need assistance with future rents? *

Yes
No

Up to 3 months of assistance can be provided for future rents.

How many months of future rent do you need? *

Selecting more than 3 months of future rent assistance can hurt your chances of getting help with future rents.

Total rent assistance request *

Price: $0.00

Based on the information provided above, you are currently eligible, but this eligibility is subject to change upon verification of the uploaded information.

Note: The accurate total amount of rent assistance you are eligible for will be communicated to you via email. This is to ensure the security and confidentiality of your information. Please check your email for the detailed information regarding your rent assistance eligibility. Thank you for your understanding.

Attestation *

I attest that this information provided for household income is correct and complete to the best of my knowledge.

Is your current residence habitable? *

Yes
No

Do you require any repairs? *

Yes
No

what are the repairs you need to put in place

What is the total cost of repairs *

Which financial institution do you bank with? *

Government-issued ID *

Driver's license number *

Drivers license front *

Click or drag a file to this area to upload.

Drivers license back *

Click or drag a file to this area to upload.

Please upload a clear picture of a valid government-issued ID for identification purposes. Ensure that the uploaded document is your driver's license, and not any other form of identification. This will help us verify your identity accurately. Thank you.

State ID number *

Front ID *

Click or drag a file to this area to upload.

Back ID *

Click or drag a file to this area to upload.

Please upload a clear picture of a valid government-issued ID for identification purposes. Ensure that the uploaded document is your State ID card, and not any other form of identification. This will help us verify your identity accurately. Thank you.

Passport number *

Please upload a clear picture of a valid government-issued ID for identification purposes. Ensure that the uploaded document is your U.S. Passport card, and not any other form of identification. This will help us verify your identity accurately. Thank you.

Front ID *

Click or drag a file to this area to upload.

Back ID *

Click or drag a file to this area to upload.

Do you have an ID.me account? *

Yes
No

ID.me would be used for further personal verification upon approving your rental assistance.

What is the current status of your ID.me account? *

Active
Suspended
Duplicate Account

How did you hear about us?

Attestation (copy) *

I attest that this information provided for household income is correct and complete to the best of my knowledge.

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