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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

About

Center for Transforming Lives works side-by-side with women and their children to disrupt the cycle of poverty throughout Tarrant County. Our services are two-generational and establish long-term financial and emotional well-being.

Center For Transforming Lives

512 West 4th Street
Fort Worth, Texas 76102

info@transforminglives.org
(817) 332-6191

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FINANCIAL Assistance Pre-Screening Application

Document List

Copies of the following:

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.

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Center For Transforming Lives

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FINANCIAL Assistance
Pre-Screening Application