Homelessness Assistance Form

2. First name (head of household)*
3. Last name*
5. Phone Number*
6. Please re-enter your Phone Number*
8. Household Size*
   -- Select One --1234567 or more
10. Email Address:*
12. Please re-enter your Email Address*
14. Please select where you slept last night:*

    1. Shelter
    2. Extended Stay/Motel/Hotel paid for by a charitable organization (not self-paid)
    3. Other
16. What is your household's hardship?*

    1. Loss of job due to lay off from Covid-19
    2. Reduced Work Hours due to Covid-19
    3. Myself or a member of my household contracted Covid-19
    4. Had to be quarantined due to someone in my household or job contracting Covid-19
    5. Other
18. If you chose "Other" above, please indicate your hardship here:
20. Please take a moment to make sure all your contact information was typed in correctly and all fields are filled in. This application is only for Homelessness Assistance. If you are in need of Rent or Mortgage Assistance and live in the City of Irving, go "Back" and choose the correct application.

    Please take a moment to make sure all your contact information was typed in correctly and all fields are filled in. This application is only for Homelessness Assistance. If you are in need of Rent or Mortgage Assistance and live in the City of Irving, go "Back" and choose the correct application.
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field