Friendly Center · Rental Assistance Eligibility Form

Rental Assistance Eligibility Form

Client Contact

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First Name

Last Name

Phone Number

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Grant Eligibility Qualifications

What Orange County city do you reside in?

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Due to your city of residence, you are ineligible for rental assistance.

Reason for Rental Assistance

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Primary: Received 3-Day Notice and/or Eviction Notice. Applicant has minor children in the home.

Secondary: Received 3-Day Notice and/or Eviction Notice. The applicant is a senior (55+), no minor children in the home.

Tertiary: Applicant is behind on rent but has not received any notice.

None of the above

Due to the reason for assistance, you are ineligible for rental assistance.

What type of rental assistance do you need?

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Monthly Rent

Deposit

First & Last Month

When is your rent due?

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Are you up to date with your rent?

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Yes

No

What is the rent amount due?

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Is the lease under your name?

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If no, do not proceed. Lease must be under the client’s name.

Yes

No

Is there an eviction notice?

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Yes

No

What is the deposit amount?

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Would you be able to provide a W-9 and a new lease for this place?

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Yes

No

Do you have Medi-Cal?

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Enter ‘Yes’ or ‘No.’ If yes, please enter your Medical Number (CIN).

What is the First & Last Month amount?

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What is the reason for your need and what brought you to Friendly Center?

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If selected, are you willing to work with a Friendly Center Case Manager for a minimum of three months to identify housing options, create a monthly budget, and receive other resources?

Yes

No

Are you currently employed?

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Yes

No

What is your household size?

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What is your monthly household income?

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Upload the following documents:

Completed and signed W-9 form from your landlord

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Photo ID

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Lease/Contract with signatures

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3 Day Notice/Eviction Notice

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Most recent paystub

Food Stamps/CalWorks award letter

Unemployment paystub

SSI/SSA award letter

Child/Spousal Support award letter

Cash Assistance award letter

Verify income eligibility. If the client does not qualify, do not proceed. Applicant will be denied.

2023 HUD Income Limits. Effective 01/01/2024.

	1 Persons	2 Persons	3 Persons	4 Persons	5 Persons	6 Persons	7 Persons	8+ Persons
50%-80%	$80,400	$101,00	$113,650	$126,350	$136,350	$146,450	$156,550	$166,650