Rental and Mortgage Assistance Program Form

2. Rental and Mortgage Assistance Form
4. Do you live in the City of Irving?*
   -- Select One --YesNo

   If your address is not in Irving, Texas, unfortunately this application will not be processed. Please call 211, option 6 for referrals in your area.
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. Apartment/Unit Number
20. City*
21. State*
22. Zip Code*
24. Household Size?*
    -- Select One --12345678910
25. How many months are you currently behind in payments?*
    -- Select One --12345 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
    2. Reduced work hours
    3. COVID-19 related hardship
    4. Unexpected emergency expenses
31. If you chose "unexpected emergency expenses" above, please indicate your hardship here.
33. Please select where you live:*

    *Unfortunately this program does not assist with Hotels/Motels, Extended Stays, or Mobile/Manufactured Homes.

    1. Apartment
    2. Single-Family Home

    1. Condo/Townhome
    2. Duplex, Triplex, Multiplex, etc...

35. 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 Rental or Mortgage Assistance. If you are in need of Homelessness Assistance, go "Back" and choose the correct application.

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