Eviction Prevention Phase II

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Click highlighted box above for Spanish Translation
The COVID-19 Eviction Prevention Program

Intake Form
Form Access: Non-profit or County Employee
Referral Type
Household AMI
90 Days+ Unemployment
Enter County Code
Unique ID copy
Assisted
No Assistance Reason
Denial Letter

Browse Files

Cancelof
Rental Assistance # of Months Requested
Rental Assistance Amount Requested
Landlord's Federal Tax ID Number
Utility Assistance # of Months
Utility Assistance Amount
Date Referral Sent

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Opened

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Referral Assigned to Case Manager

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Closed Out

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Case Status
Notes

0/500
Funding Source
Assistance Amount Provided
Number of Seniors (65 and Older) in the Household
Number of Disabled Persons in the Household
Case Referred To
Subset
DO NOT ASSIGN REASON
Making Changes to the Assignment?
Assigned To
Original Assignment
Original Assignment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Re-Assignment
Re-Assignment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Check here once the assignment is finished
Eligibility Questions
Are you at least 18 years of age?
You must be at least 18 years of age to apply.
Date of Birth
Birth Date MUST be before 12/31/2002
Do you currently reside in Baltimore County?
You must reside in Baltimore County to be eligible for this assistance. Please contact the County in which you reside to determine if they can assist you.
Has any adult member of your household (18 years of age or older) including yourself been unemployed for at least 90 days prior to application for assistance
Are you applying for rental assistance?
Do you have a signed lease for the rental property?
You must have a signed lease for the rental property
Is your name on the lease?
Are you currently receiving a Housing Choice Voucher or some other type of subsidized housing voucher?
County residents receiving a Housing Choice Voucher or other rental subsidy through the Baltimore County Office of Housing, must call 410-887-2766 to update current income for rent payment recalculation and to inquire about assistance.
How many months of rental assistance are needed?
What is your monthly rent?
If your monthly rent is less then 1000.00 please enter a zero in the front
If applying for rental assistance, was eviction pending before March 1, 2020?
This program was designed to assist applicants with eviction prevention due to the COVID-19 pandemic you are not eligible for this program.
How many people live in your household?
What is the annual income of the household?
What is the annual income of the household?
What is the annual income of the household?
What is the annual income of the household?
What is the annual income of the household?
What is the annual income of the household?
What is the annual income of the household?
What is the annual income of the household?
Enter number of people in your household
What is the annual income of the household?
Are you applying for utility assistance?
Is your name (or the name of someone residing in the unit) on the utility bill?
Your name or the name of someone residing in the unit must be on the utility bill to be eligible for utility assistance.
If applying for utility assistance, how many months of utility assistance are needed?
If applying for utility assistance, was shutoff pending before March 1, 2020
This program was designed to assist applicants with utility shutoff assistance due to the COVID-19 pandemic you are not eligible for this program.
Applicant Information
First Name
Last Name
Street Address
DO NOT put Unit, Apartment Numbers, City or State in this field. Number and Street Name only
Unit/Apt #
Enter N/A if you do not have a Unit or Apartment Number
City
State
Zip Code (5 digits)
Phone Number
Do you have a valid Email Address
Email Address
Ethnicity
Race
Gender
Last 4 Digits of your SSN
Enter 0000 if you don't know your Social Security Number or do not have one
Highest level of completed education
Household Information
Female headed household
Number of children (under 18) who reside in the household
Number of adults (including yourself who are 18 years of age or older) who reside in the household
Number of seniors (65 years of age or older including yourself) who reside in the household
Is a language other than English spoken at home?
What is the primary language spoken in the household?
How well do you speak English?
Is any member of the household a U.S. military veteran?
Have you previously received COVID-19 Eviction Prevention Assistance?
Month of Eviction Prevention Assistance?
Year of Eviction Prevention Assistance?
Are you currently or have you previously worked with any of the following?
Are you currently receiving any Public Assistance Benefits?
Landlord Information
Property Management Company
Landlord's Full Name
Landlord's Address Line 1
Landlord's Address Line 2
Please verify that you are human
Landlord's City
Landlord's State
Landlord's Zip Code (5 digits)
Property Management Company or Landlord's Phone Number
Property Management Company or Landlord's Email Address
Utility Service Company Information
Utility Company Name
Street Address Line 1
Street Address Line 2
City
State
Zip Code (5 digits)
Phone Number
Should be Empty:

The COVID-19 Eviction Prevention Program