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FINANCIAL Assistance
Pre-Screening Application

Currently, financial assistance for the general public is limited to Fort Worth residents impacted by COVID-19.

Date:
First Name:
Last Name:
Email Address:
Cell Phone:
Alternate Phone:
Date of Birth:
Home Address:
1. Are you a CTL employee?:
2. Type of assistance requested:
3. Are you at risk of losing your housing for one or more of the following financial reasons? Check all that apply:
4. Are you interested in being referred to other services to improve financial stability?:
5. Do you currently receive or live in any of the following Public Housing/Housing Choice Voucher (Section 8)/Project Based Voucher Program Participants?::
6. Do you receive rental assistance through another agency?:
7. Are you living in a hotel or motel room paid for by the government, or in an emergency shelter?:
8. Is an immediate family member your landlord?:
9. What type of housing do you reside in right now?:

10. How many persons live in your home, including you? Insert numbers below.
Total:
Adults:
Children:
Roommates:
11. Does anyone in your household have income right now? (Income may come from these sources Work, Unemployment, Social Security, SSI, Pension, Other)::
12. Did anyone in your household have income in the past 30 days? (not including the stimulus check):
13. Has anyone in your household received notice that they will start receiving income? (For example, starting a new job, starting unemployment benefits, etc.):

14. Who has income now and include If anyone in the household has or will have income (not including the stimulus)?

Income may come from these sources: Work, Unemployment, Social Security, SSI, Pension, Other

Specify the gross amount. (Before any deductions) How often are you paid? Monthly, Twice a month, Every two weeks, Every week, Daily (includes people paid upon completion of each work assignment that lasts less than one day)

No income (skip filling in info):
Household Member Name (1):
Gross Amount By Source (1):
Paid How Often? (1):
Household Member Name (2):
Gross Amount By Source (2):
Paid How Often? (2):
Household Member Name (3):
Gross Amount By Source (3):
Paid How Often? (3):
15. Have you received an eviction notice or lease violation notice?:

16. What is the name and contact number or email of your landlord? (For example, who do you write your check or money order to each month)
Landlord:
Apt Complex Name:
Landlord Phone Number:
Payment mailing address:
Email Address:
Customer ID number/Account number:
Total normal monthly payment:
Total amount currently due:
Thank you for completing a pre-screening survey application for the CTL Rental Assistance Program. Depending on where your pre-screening application survey falls in line, the next step would be to hear from the Program Coordinator. The goal is to contact applicants within 3 business days. Please ensure you have the required documents in preparation for the call. Without the required documentation, applications cannot be processed. Submission is not a guarantee of assistance or a guarantee that you will receive a call for the next stage, as applications are processed on a first come first serve basis. CTL is committed to processing as many applications as there is funding, however, there is anticipation for high demand.

Document List

  • Provide documentation of the impact of COVID-19 to their circumstance, including but not limited to the following:
  • Proof of job/income loss, temporary or permanent
  • Reduction in work hours/income
  • Increased healthcare and household expenses that attributed to insufficiency of rent payments (i.e. increased child-care expenses due to school closures).
Copies of the following:
  • Valid, current Passport or
  • State ID Card or
  • Driver’s license (for each adult in the household)
  • A copy of your current lease
  • Late or eviction notice(s) for monthly rent or proof of circumstance (any paperwork that can support how the household was adversely affected by COVID-19).
  • Proof of income, if any (unemployment benefits, check stubs, TANF, etc.)
  • Proof of occupancy for all household members

By my signature, I acknowledge that I have read, understand, and agree to the requested information, and I have responded with true and accurate information.
Applicant/Leaseholder Signature:
Date:

For additional information or to follow up on the status of an application, email financialassistance@transforminglives.org