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ND COVID Emergency Rent Bridge
Pre-Qualification Survey
Tell us about yourself and your household
Name
Address / Apt #
City
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
Phone (ex. 701-999-9999)
Email
Confirm Email Address
Number of people in your household (including yourself)
Race/Ethnicity
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
Rental Arrangement
Name of person/company you pay rent to
Do you have a lease?
Yes
No
Number of bedrooms in Rental Unit
Is this property your primary residence?
Yes
No
Circumstances of Hardship
Is your current economic hardship due to COVID-19?
Yes
No
Occupation
What is the nature of the hardship?
Can't find a job / no hiring
Can't find child care
Ineligible for Unemployment benefits
Loss of job
Reduction in hours
Unable to work due to health
Other
Please describe
Financial Information (include pre-tax income of all household members age 18+)
What was your household’s monthly gross income before you experienced your current hardship?
What is your household's monthly gross income now?
You reported having Zero income. Please describe how your family is meeting basic daily needs.
What is your monthly rent payment?
Do you have a checking account?
Yes
No
Do you have a savings account?
Yes
No
Do you have savings (ex. checking acct, savings acct) that are greater than 3 times the amount of your rent?
Yes
No
Utilities
Do you pay your own utilities?
Yes
No
If yes, average monthly utility costs (gas, electrical, water, and sewer)
Utility Company
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
Rental Assistance
Are you current on your rent payment?
Yes
No
If no, how many months do you owe?
Current month past due
Both last month and current month past due
More than 2 months past due
Have you received rental assistance in the last 6 months?
Yes
No
If yes, source of assistance?
Are you currently receiving rental assistance?
Yes
No
Have you received an eviction notice?
Yes
No
Have you applied for / been approved for other economic assistance?
SNAP (Supplemental Nutrition Assistance)
Applied
Approved
Not applied
Amount of SNAP benefit
LIHEAP (Home Energy Assistance Program)
Applied
Approved
Not applied
Unemployment Insurance
Applied
Approved
Not applied
If you have not applied or were not approved, please list reason
