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2. City of Colton - Homeless Housing Assistance & Prevention Program Eligibility Application

   This form is used to help the City of Colton Community Services Department determine if you are eligible to receive assistance through the Homeless Housing Assistance and Prevention Program. All applicants must complete this application in full otherwise application will not be considered. All applications and documents are reviewed after the 20th of each month. All communication will be through email during the application process. Status of application will not be given over the phone. Requests for assistance is prioritized based on identified criteria and determination of immediate needs. If you need assistance completing this application please contact, 909-370-5087 or email homeless@coltonca.gov for assistance.

4. Applicant and Household Information
6. First Name*
7. Last Name*
9. Address *
11. City*
12. State*
13. Zip*
15. Phone Number*
16. Email Address*
18. How many adults in household?*
    -- Select One --12345+
20. How many minors (under 18) in the household?*
    -- Select One --012345+
22. Assistance Type
24. What type of assistance are you applying for?*
    -- Select One --Eviction PreventionRapid Re-Housing
26. Are you at imminent risk of losing your housing?*
    -- Select One --YesNo
28. Housing Information
30. Landlord/Property Manager Name:*
32. Landlord/Property Manager Phone Number:
34. Landlord/Property Manager Email Address:
36. Are you currently behind on your monthly rent payment?*
    -- Select One --YesNo
38. How many months are you behind on rent?*
40. Monthly Rent Payment (as shown on lease):*
42. Have you received other rental assistance in the last 24 months?*
    -- Select One --YesNo
44. If yes, what type of assistance, agency name, and dates assistance was provided?*
46. Current Lease Agreement *

    Attach your current lease agreement, cannot be expired. If expired, an explanation letter from landlord is required. 

48. Pay or Quit Notice*

    Attach a current pay or quit notice, eviction notice, notification of rent due, or letter written by landlord showing amount due.

50. Income Information
52. Are you currently employed?*
    -- Select One --YesNo
54. What is your household's monthly income? *
56. If provided assistance for your current situation, do you have the ability to sustain stable housing without further assistance?*
    -- Select One --YesNo
58. Proof of Income Documentation*
    Attach ONE MONTH worth of income documentation for all adults in household (employment income, cash aid, food stamps, unemployment, workers compensation, etc.).
60. Proof of Income Documentation
    Use if needed to attach multiple income documents.
62. Proof of Income Documentation
    Use if needed to attach multiple income documents.
64. Explain/describe your plan in detail on how you will sustain your housing after assistance is provided.*

66. The City of Colton Community Services Department will offer one-time rental assistance to help renters in the City of Colton. The program is made possible with funds from the Homeless Housing Assistance and Prevention Program (HHAP) provided by the State of California and County of San Bernardino. Payments are made directly to landlords. Applications for assistance are processed on a first come, first served basis. Applications will be processed until all funding is exhausted. Applications will not be processed without required documentation.

    I authorize City of Colton Community Services to release and share information from my records regarding personal information including but not limited to: services I received, physical and mental health, and employment status - for the express purpose of receiving or gaining access to services related to my current or future needs. I understand that at any time it may be necessary for City of Colton Community Services to share information or request information from other agencies (public and non-profit) and other sources, but not limited to landlords, service providers, etc. I hereby authorize City of Colton Community Services to seek and/or share information relevant to my request for assistance from City of Colton Community Services. I understand that I am NOT guaranteed this assistance. This consent is valid from the date signed and maybe revoked at any by verbally informing the agency holding this original form. I understand that I have a right to limit the scope of this consent form. I understand that City of Colton Community Services has a legal responsibility to involve other parties as necessary under the following conditions: 1. If the participant or family member threatens suicide, threatens harm of another person(s) including homicidal threats, assault and/or physical harm. 2. If the Case Manager or other staff has knowledge of or observes a child/youth, an elder adult, or a dependent adult whom the Case Manager and/or other staff knows or reasonably suspect has been a victim of abuse.

    I understand and by signing, agree that all information I have provided in this application is true and correct to the best of my knowledge. I agree to notify promptly in writing upon any change in the information provided herein. The City of Colton is authorized to make inquiries, as deemed necessary and appropriate to verify the accuracy of this application. The information supplied is used strictly for establishing eligibility for the City of Colton Community Services one-time rental assistance program. Applicant(s) acknowledges that personal and financial information may be subject to public disclosure under the California Public Records Act. If chosen for funding, applicant will be required to provide additional qualifying documentation. Submission of application does not guarantee assistance.

68. Sign Name:*
69. Date:*
    Date:
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

* indicates a required field