Rent Assistance Prescreen2 : Housing Stability : Programs : Community Action

Rent Assistance Prescreen

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Do you live in Washington County, Oregon?

We can only serve households who live in Washington County, Oregon.

Has your household received rental assistance from the Emergency Rent Program in the past 6 months?

Yes; I do not qualify
No; I do qualify

Did you recently receive a Notice for Non-Payment of Rent?

Yes; I qualify
No; I do not qualify

To be eligible you MUST have a pending nonpayment eviction notice.

Please Enter the Date you were served the Notice of Non-Payment of Rent

Is the Household's gross income under 50% Area Median Annual Income Guidelines?

Yes, I am under.
No, I am over.

HOUSEHOLD SIZE: (1) $39,500; (2) $45,150; (3) $50,800; (4) $56,400; (5) $60,950; (6) $65,450; (7) $69,950; (8) $74,450

First Name

Last Name

Date of Birth

(MM/DD/YYYY)

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Phone

E-mail Address

Total amount of GROSS monthly income (before any taxes or deductions) that the household has received. This includes wages, Social Security, TANF, child support, etc.

Number of people in your household

When does your current lease end? Please provide month and year (mm/yyyy)

What past months do you currently owe of rent?

Primary reason you are seeking rental assistance

If English is not your preferred language, please let us know in what language we should contact you:

Is there anything else you would like us to know as we process your application?

Thank you, once you submit this request you will receive a confirmation receipt with a tracking number if your prescreen request was received successfully.