City of Carlsbad Rental Assistance Screening

Please Note:

This is not an application. Completion of this screening does not qualify nor disqualify you from any supportive services (including rental assistance).

Based on the needs of each household, support could include emergency rental assistance, rental arrears and late fees, utility assistance, landlord mediation/advocacy, new move-in expenses and employment assistance for individuals who reside within the City of Carlsbad.

Question Title

* Who is completing this screening?

Self; Head of Household

Friend, Caregiver, Other (please provide your name below0

Interfaith Representative (please provide your name below)

If Other, please specify your name, relationship to head of household, and whether the client knows that you are completing this screening on his/her behalf:

Question Title

* Please provide the following contact information.
We will only utilize this information to contact you regarding your screening.

Full Name

Apartment Complex Name

City/Town

ZIP/Postal Code

Email Address

Phone Number

Question Title

* Date of Birth (Head of Household)

This will only be utilized for identification purposes.

Date

Question Title

* How many individuals currently live in your household?

	Adults (Ages 18+)	Children (under the age of 18 yrs. old)
Household Size	Household Size Adults (Ages 18+) menu	Household Size Children (under the age of 18 yrs. old) menu

Question Title

* What is the employment status for the primary adults in your household?

	Employment Status
Head of Household	Head of Household Employment Status menu
Second Adult	Second Adult Employment Status menu
Third Adult	Third Adult Employment Status menu
Fourth Adult	Fourth Adult Employment Status menu

Question Title

* What is your total household income per month?

Income may be defined as and includes all cash benefits that your household receives.

17% of survey complete.

City of Carlsbad Rental Assistance Screening

Please Note:

Question Title

* Who is completing this screening?

Question Title

* Please provide the following contact information. We will only utilize this information to contact you regarding your screening.

Question Title

* Date of Birth (Head of Household)

Question Title

* How many individuals currently live in your household?

Question Title

* What is the employment status for the primary adults in your household?

Question Title

* What is your total household income per month?Income may be defined as and includes all cash benefits that your household receives.

* Please provide the following contact information.
We will only utilize this information to contact you regarding your screening.

* What is your total household income per month?

Income may be defined as and includes all cash benefits that your household receives.