MCHENRY COUNTY HOUSING AUTHORITY

First Name

Middle Initial

Last Name

Number of people living in your household, including yourself:

Your email

Your phone number

Have you lived in McHenry County for at least all of the past 30 days?
YesNo

Current address

Describe your living situation. For example, are you: renting an apartment or a house, renting a room, staying with a friend, staying in a halfway house or sober living house, homeless and staying in a shelter or in a tent, etc.

How much is your monthly rent?

How much do you currently owe in past-due rent?

Do you have a late notice in writing from your landlord?
YesNo

Do you have a year-to-year lease?
YesNo

What caused you to get behind in your rent? Please be detailed and specific.

Is your landlord willing to let you stay if you get your rent caught up?
YesNo

How much gross income (before taxes) does your full household receive right now each month and what are the sources of the income? Include all sources of income, such as wages, Social Security, child support, cash, etc.

If you have applied for rent assistance from any other organization, what is the name(s) of the organization(s) and how much were you approved to receive?