PY 27 Rental Applicaton

Please read the following information carefully before submitting your application:

Incomplete applications will be denied. All required documentation must be submitted before your application can be reviewed.

Assistance is limited to households seeking housing in Rock Island, Henry, or Mercer Counties.

Applicants must demonstrate the ability to maintain ongoing rent payments after assistance is provided.

Applicants must have a valid, documented temporary financial crisis beyond their control that meets program eligibility requirements.

If additional documentation is requested or needs to be submitted after completing the application, please email it to housing@projectnow.org with your full name in the subject line.

The application review process may take up to 30 days from the date a complete application is received.

Funding is available on a first-come, first-served basis and is subject to available funds.

Submitting an application does not guarantee funding. Eligibility, documentation, program requirements, and funding availability will all be considered before assistance is approved.

By submitting an application, you acknowledge that you have read and understand these requirements.
Project NOW Rental Application
I am applying for assistance with:
Name

First NameLast Name
Social Security Number
Are you a U.S. Military Veteran
Sex
Date of Birth

MonthDayYear
Date
Race and Ethnicity (select all that apply)
Phone
Format: (000) 000-0000.
Email
example@example.com
Do you have a permanent address?
Address

Street Address

CityState / Province

Postal / Zip Code
Where did you sleep last night?
Where did you sleep last night?
Date your 5 day eviction notice was issued by your landlord:

MonthDayYear
Date
When was the approximate date of the last time you had a permanent address?

MonthDayYear
Date
How long have you been there?
Do you have income?
Total Income for the last 30 days:
What type of income do you have (select all that apply)
Do you receive non-cash benefits (SNAP, WIC, ect) ?
Select all non-cash benefits that you receive:
Do you have health insurance?
What type of health insurance do you have (select all that apply):
Do you have a disabling condition?
Disabling Condition Type (check all that apply):
Are you a survivor of domestic violence?
If yes, when did you experience occur?
Are you currently fleeing?
Do you have additional Adults in your home? (Anyone 18 or older)
How many additional adults?
Do you have any children in your home?
How many children are in your home?
Adult Household Member #2
Name

First NameLast Name
Social Security Number
Are you a U.S. Military Veteran
Sex
Date of Birth

MonthDayYear
Date
Race and Ethnicity (select all that apply)
Phone
Format: (000) 000-0000.
Email
example@example.com
Do you have a permanent address?
Address

Street Address

CityState / Province

Postal / Zip Code
Where did you sleep last night?
Where did you sleep last night?
Date your 5 day eviction notice was issued by your landlord:

MonthDayYear
Date
When was the approximate date of the last time you had a permanent address?

MonthDayYear
Date
How long have you lived there?
Do you have income?
Total Income for the last 30 days:
What type of income do you have (select all that apply)
Do you receive non-cash benefits (SNAP, WIC, ect) ?
Select all non-cash benefits that you receive:
Do you have health insurance?
What type of health insurance do you have (select all that apply):
Do you have a disabling condition?
Disabling Condition Type (check all that apply):
Are you a survivor of domestic violence?
If yes, when did you experience occur?
Are you currently fleeing?
Adult Household Member #3
Name

First NameLast Name
Social Security Number
Are you a U.S. Military Veteran
Sex
Date of Birth

MonthDayYear
Date
Race and Ethnicity (select all that apply)
Phone
Format: (000) 000-0000.
Email
example@example.com
Do you have a permanent address?
Address

Street Address

CityState / Province

Postal / Zip Code
Where did you sleep last night?
Where did you sleep last night?
Date your 5 day eviction notice was issued by your landlord:

MonthDayYear
Date
When was the approximate date of the last time you had a permanent address?

MonthDayYear
Date
How long have you lived there?
Do you have income?
Total Income for the last 30 days:
What type of income do you have (select all that apply)
Do you receive non-cash benefits (SNAP, WIC, ect) ?
Select all non-cash benefits that you receive:
Do you have health insurance?
What type of health insurance do you have (select all that apply):
Do you have a disabling condition?
Disabling Condition Type (check all that apply):
Are you a survivor of domestic violence?
If yes, when did you experience occur?
Are you currently fleeing?
For Additional Adults please add their information in the comment section of this application.
First Child
Child's Name (1)

First NameLast Name
Social Security Number
Sex
Date of Birth

MonthDayYear
Date
Race and Ethnicity (select all that apply)
Do you have a disabling condition?
Disabling Condition Type (check all that apply):
Child #2
Child's Name (2)

First NameLast Name
Social Security Number
Sex
Date of Birth

MonthDayYear
Date
Race and Ethnicity (select all that apply)
Do you have a disabling condition?
Disabling Condition Type (check all that apply):
Child # 3
Child's Name (3)

First NameLast Name
Social Security Number
Sex
Date of Birth

MonthDayYear
Date
Race and Ethnicity (select all that apply)
Do you have a disabling condition?
Disabling Condition Type (check all that apply):
Child #4
Child's Name (4)

First NameLast Name
Social Security Number
Sex
Date of Birth

MonthDayYear
Date
Race and Ethnicity (select all that apply)
Do you have a disabling condition?
Disabling Condition Type (check all that apply):
Child # 5
Child's Name (5)

First NameLast Name
Social Security Number
Sex
Date of Birth

MonthDayYear
Date
Race and Ethnicity (select all that apply)
Do you have a disabling condition?
Disabling Condition Type (check all that apply):
I understand that my application for rental or deposit assistance may be reviewed for eligibility under multiple funding sources and assistance programs administered by Project NOW, Inc.

I understand that the Level Up Program is a funding source available to eligible residents of the City of Moline. By signing below, I authorize Project NOW to use the information and documentation I have provided to determine my eligibility for Level Up and other available assistance programs.

If I am determined eligible for Level Up funding, I voluntarily consent to participate in the Level Up Program and understand that program requirements may include case management services, collection of program-related information, and reporting requirements necessary for program administration and evaluation.
Please upload a copy of your Photo ID.

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Please upload Social Security Numbers for all household members.

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Please upload the last 30 days of Income for anyone in the home receiving any.

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If you are facing an eviction, please upload a copy of your 5-day eviction notice.

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Please upload your lease.

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What caused you to get behind on your rent (crisis)?
Please upload documentation of crisis.

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Should be Empty:

Project NOW Rental Application

Adult Household Member #2

Adult Household Member #3

For Additional Adults please add their information in the comment section of this application.

First Child

Child #2

Child # 3

Child #4

Child # 5