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ND Rent Help
Pre-Qualification Survey
Tell us about yourself and your household
Name
*
*
Address / Apt #
*
*
Email
*
*
*
Phone (ex. 701-999-9999)
*
*
City
*
*
Confirm Email Address
*
*
*
Occupation
*
*
Zip Code
*
*
County of residence
*
Adams
Barnes
Benson
Billings
Bottineau
Bowman
Burke
Burleigh
Cass
Cavalier
Dickey
Divide
Dunn
Eddy
Emmons
Foster
Golden Valley
Grand Forks
Grant
Griggs
Hettinger
Kidder
LaMoure
Logan
McHenry
McIntosh
McKenzie
McLean
Mercer
Morton
Mountrail
Nelson
Oliver
Pembina
Pierce
Ramsey
Ransom
Renville
Richland
Rolette
Sargent
Sheridan
Sioux
Slope
Stark
Steele
Stutsman
Towner
Traill
Walsh
Ward
Wells
Williams
Household members (include anyone who lives in the household and considers this location their permanent home)
Number of people in your household (including yourself)
*
*
*
Household Member #1 Age
*
*
*
Sources of Income (if age 18+)
*
*
Household Member #2
*
Age
*
*
Sources of Income (if age 18+)
*
Household Member #3
*
Age
*
*
Sources of Income (if age 18+)
*
Household Member #4
*
Age
*
*
Sources of Income (if age 18+)
*
Household Member #5
*
Age
*
*
Sources of Income (if age 18+)
*
Household Member #6
*
Age
*
*
Sources of Income (if age 18+)
*
Establishing Household Eligibility
Are you currently experiencing homelessness?
*
Yes
No
Are you currently unemployed for 90 days or longer?
*
Yes
No
Has anyone in your household qualified for unemployment benefits OR experienced a reduction in income OR had increased expenses during any period of time on or after March 13, 2020, due directly or indirectly, to the pandemic?
*
Yes
No
Have you received an eviction notice?
*
Yes
No
Are you past due on rent?
*
Yes
No
Are you past due on utilities?
*
Yes
No
What was your household’s monthly gross income before you experienced your pandemic related hardship?
*
*
What is your household's monthly gross income now?
*
*
Please provide a detailed explanation of how your households financial status has been impacted. What date did your financial hardship begin? What circumstances occurred that lead to your financial hardship?
*
Rental Arrangement
Name of person/company you pay rent to
*
*
Do you have a lease?
*
Yes
No
What is your monthly rent payment?
*
*
Is this property your primary residence?
*
Yes
No
Number of bedrooms in Rental Unit
*
*
*
Do you pay your own utilities?
*
Yes
No
Utilities
Utility Company
*
Average monthly utility costs (gas, electrical, water, and sewer)
*
Heat Payor
Owner Paid
Renter Paid
Heat Source
Electric
Natural Gas
Other
Cooking Payor
Owner Paid
Renter Paid
Cooking Source
Electric
Natural Gas
Other
Water Heating Payor
Owner Paid
Renter Paid
Water Heating Source
Electric
Natural Gas
Other
Electricity Payor
Owner Paid
Renter Paid
Water/Sewer Payor
Owner Paid
Renter Paid
Garbage Payor
Owner Paid
Renter Paid
Have you qualified/been approved for any of the following economic assistance programs?
SNAP
*
Yes
No
TANF
*
Yes
No
Head Start/Early Head Start
*
Yes
No
LIHEAP
*
Yes
No
WIC
*
Yes
No
Childcare Assistance
*
Yes
No
Supplemental Security Income (do not include SSDI & SSA Retirement Benefits)
*
Yes
No
Race/Ethnicity/Gender
What is your gender?
*
Female
Male
Nonbinary
Declined to Answer
Data Not Collected
Household is Hispanic or Latino
*
Yes
No
Check that category that best describes the Head of Household (can select multiple)
White
Black
Asian
American Indian
Multi-Racial
Other
Attestation
I attest to the accuracy of the information provided above.
This application is not complete till supporting documents have been provided.
I have read and understand the statements above.
*
Yes
No
