Rental and Mortgage Assistance Program Form

2. Rental and Mortgage Assistance Form

4. Do you live in the City of Irving?*
   -- Select One --YesNo

5. Which type of assistance are you seeking?*
   -- Select One --RentalMortgage

7. First Name (head of household)*

8. Last Name*

10. Email Address*

12. Please re-enter your email address*

14. Phone Number*

15. Please re-enter your Phone Number*

17. Address*

18. Apt. Number /P.O. Box

20. City*

21. State*

22. Zip*

24. Household Size?*
    -- Select One --12345678910

25. How many months are you currently behind in payments?*
    -- Select One --1234 or more

27. What is the gross monthly income for the past 30 days, for the entire household?*

29. What is you or 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" non COVID-19 related hardship (indicate below)

31. If you chose "Other" above, please indicate your hardship here. (Only if it is non COVID-19 related)

33. Please select where you live:*

    1. Apartment (no hotels/motels, or extended stays)
    2. Single-Family Home
    3. Condo/Townhome

    1. Mobile Home
    2. Duplex, Triplex, Multiplex, etc...

35. What is your preferred method of contact to receive official correspondence?*

    1. Regular postal mail
    2. E-mail

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field