subject_line
HomeSafe Application
First Name
*
Last Name
*
Suffix
Email Address
*
Phone Number
*
Phone Type
*
Home
Work
Mobile
Voicemail Only
Street Address
*
Apt #
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Postal Code
*
Birthdate
*
+
Social Security Number
Preferred Language/Languaje Preferido
*
English/Inglés
Spanish/Español
Ethnicity
🛈
Hispanic or Latino
Not Hispanic or Latino
Choose not to Respond
Race
🛈
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Multiple Races
Choose not to respond
Marital Status
Single
Divorced
Married
Legally Separated
Widowed
Gender
Male
Female
Other
Education
🛈
Unknown
Elementary
Junior High School
High School
Junior College
University
Graduate School
Other
Employment Status
*
Employed full time
Employed part time
Unemployed and looking for work
Unable to work due to disability
Stay-at-home caregiver or parent
Retired
Student
Other
Please upload proof of employment status.
*
🛈
RI resident for the last 365 days?
*
🛈
Yes
No
Are you involved in a DV situation?
*
Yes
No
Please be ready to provide proof of a DV situation, such as a waiver or police report.
Please upload your RI license that proves RI residence for 365 days, or other proof of residency
*
🛈
Household Size
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Please upload the first page of your most recent tax return which lists the names of each household member
*
Household Names and Birthdates
*
🛈
Please upload the past 2 months of bank statements for each adult living in the household
*
Active member of the U.S. Military?
Documentation of military income benefits
*
Veteran of the U.S. Military?
Documentation of military income benefits
*
Household members in Military or Veteran?
🛈
Documentation of military income benefits
*
Are you legally disabled?
🛈
Please upload SSI/SSDI award letter
*
Is anyone else in the household disabled?
🛈
Please upload SSI/SSDI award letters for each disabled household member
*
I own rental property
🛈
Please upload rent receipts or bank statement showing rental deposits.
*
I receive child support
🛈
Please upload statement screen from child support database showing payee and amounts.
*
I have a Section 8 Voucher
Please upload copy of Section 8 voucher or letter from issuing agency.
*
Current short-term emergency
*
🛈
Temporary Sickness or Disability
Loss of income in the past 90 days
Moving from Shelter to Permanent Housing
Need to move due to Domestic Violence
Need to move due to threat of lead paint poisoning to children
Need to move due to fire or other disaster
Need to move due to severe code violations or condemnation
Need to move due to foreclosure or eviction
Please upload TDI letter
*
Please upload letter from shelter proving homelessness
*
Please upload copy of DV Waiver
*
Please upload letter from DOH or building inspector documenting lead paint
*
Please upload letter from the Red Cross documenting fire/disaster.
*
Please upload letter from building inspector documenting code violation.
*
Please upload mortgage statement & lawyers letter or 30 day termination letter.
*
I need financial assistance with:
*
Past due rent
Past due mortgage
Late Fees on rent or mortgage
Moving expenses
Past due utilities
Please upload 5 day demand letter or landlord letter & lease
*
Please upload mortgage statement.
*
Please upload lease and 5 day demand letter or mortgage statement.
*
Please upload moving bill/quote from moving company.
*
Please upload complete utility bill for each past due service.
*
Briefly describe your situation.
*
🛈
Total amount of assistance needed
*
🛈
How do you plan to make future payments?
*
🛈
Have you applied for Housing Assistance elsewhere?
*
🛈
Yes
No
Where did you apply?
*
For which months did you apply?
*
What type of assistance did you apply for?
*
mortgage
rent
utilities
other
Were you funded?
*
Yes
No
I certify truthful information
*
🛈
Agree
I agree to application review
*
🛈
Agree
I authorize contact with my creditor
*
🛈
Agree
I understand any payment is to creditor
*
🛈
Agree