Rental Assistance Request Form
Applications OPEN
If you are on a smart phone, you must scroll all the way down to review the declaration section.

Name*

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Phone Number*

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E-mail*

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The e-mail address is invalid

Address*

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Number of Adults in Household*

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Number of Children in Household*

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Total Household Income (Monthly)*

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Landlord's Name & Contact Info*

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Rental Property Address & Monthly Rent Amount (Must be in New Jersey)*

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Assistance Amount Requested*

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Have you received rental assistance from any other source in the past 12 months(this includes Section 8, ERAP HPP Funds, etc.)? Yes/No*

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Have you been served with an eviction notice, judgment of possession, warrant of removal, etc.? Yes/No*

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Is this an emergent request (pending lockout, already locked out, currently homeless, etc)? Yes/No*

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Reason for Rental Assistance Request: (Provide a brief explanation of why rental assistance is needed, including any relevant circumstances such as job loss, medical emergencies, etc.) *

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Check here to acknowledge that you read and understand the Declaration*

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Check Here that you agree to creating your electronic signature and signing the document just as if you had used a pen to ink sign *

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Electronic Signature (Type your full name)*

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* Indicates required fields

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Thank you! We will get back to you as soon as possible.

Telephone: +1 856 390 3091

E-mail: jflinn@SouthJerseyHousing.org

Declaration:

By signing this form, you authorize South Jersey Housing Assistance Fund to use the information provided freely and as needed to attempt to raise funds and/or provide you with assistance. This means you are giving us your express permission to share all parts of this form with prospective donors, your landlord, other organizations, etc.

PLEASE NOTE: This is not a promise to pay any party and it is not guaranteed that any or all applicants will receive rental assistance. This form collects information from those requesting assistance. Once reviewed and if deemed eligible we will attempt to locate monetary resources to assist from various sources such as governmental and private grants, donations, and fundraisers. Do NOT rely on this as your only option to avoid an eviction.

South Jersey Housing Assistance Fund, a NJ Nonprofit Corporation, is an exempt organization as described in Section 501(c)3 of the Internal Revenue Code; EIN #92-1607103.

South Jersey Housing Assistance Fund
A NJ Nonprofit Corporation
PO BOX 12, Williamstown, NJ 08094
Call/text 856-390-3091
jflinn@SouthJerseyHousing.org

an exempt organization as described in Section 501(c)3 of the Internal Revenue Code; EIN #92-1607103.

SouthJerseyHousing.org

Rental Assistance Request FormApplications OPENIf you are on a smart phone, you must scroll all the way down to review the declaration section.

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Rental Assistance Request Form
Applications OPEN
If you are on a smart phone, you must scroll all the way down to review the declaration section.