Eviction Prevention Phase II

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Click highlighted box above for Spanish Translation

Form Access: Non-profit or County Employee

Non-profit County Employee

Enter County Code

Unique ID copy

Assisted

Yes No Contested

No Assistance Reason

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

Date

Date Received

Date

Date Opened

Date

Date Referral Assigned to Case Manager

Date

Date Closed Out

Date

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

Subset A Subset B Subset C

DO NOT ASSIGN REASON

Making Changes to the Assignment?

Yes (Re-assign) No (First-time Assignment)

Assigned To

Original Assignment

Original Assignment Date

Date

Re-Assignment

Re-Assignment Date

Date

Check here once the assignment is finished

Check here

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? *

Your name must be on the lease to be eligible for rental assistance.

Are you currently receiving a Housing Choice Voucher or some other type of subsidized housing voucher?

Thank you for requesting assistance through Baltimore County's Eviction Prevention Portal. Housing Choice Voucher and other subsidized housing voucher holders should seek assistance through the Baltimore County Office of Housing. Voucher holders cannot be assisted through this funding source and should call the Housing Office at 410-887-2766

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?

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

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

The COVID-19 Eviction Prevention Program