1.Have you or someone in your household been affected financially by COVID-19 (qualified for Unemployment Benefits or experienced a reduction in income) ?

Yes

No

2.Are you or someone in your household behind in paying rent?

Yes

No

3.What is your monthly rent

Below $1000.00

$1000.00 to $1500.00

$1500.00 to $2000.00

$2000.00 to $ 2500.00

$2500.00 to $3000.00

Above $ 3000.00

4.How much rent arrears do you owe?

$0.00

$0.00 to $1000.00

$1000.00 to $2500.00

$2500 to $5000.00

$5000.00 to $7500.00

$7500.00 to $10,000.00

more than 10,0000.00

5.How many months are you behind in paying your rent ?

0 months

1 to 3 months

3 to 6 months

6 to 9 months

9 to 12 months

more than 12 months

6.What is your ZIP code ?

10901 Airmont10952 Airmont10954 Bardonia10911 Bear Mountain10913 Blauvelt10960 Central Nyack10952 Chestnut Ridge10965 Chestnut Ridge10977 Chestnut Ridge10920 Congers10923 Garnerville10960 Grandview10969 Grandview on Hudson10980 Grassy Point10927 Haverstraw10931 Hillburn10952 Monsey10901 Montebello10970 Mount Ivy10954 Nanuet10956 New City10977 New Hempstead10977 New Square10960 Nyack10962 Orangeburg10964 Palisades10965 Pearl River10968 Piermont10970 Pomona10974 Sloatsburg10960 South Nyack10976 Sparkill10977 Spring Valley10980 Stony Point10901 Suffern10952 Suffern10982 Tallman10983 Tappan10984 Thiells10986 Tomkins Cove10960 Upper Grandview10960 Upper Nyack10989 Valley Cottage10952 Wesley Hills10977 Wesley Hills10993 West Haverstraw10994 West Nyack

7.

Area Median Income	1 person	2 people	3 people	4 people	5 people	6 people	7 people	8 people
50% AMI	$39,800	$45,500	$51,200	$56,850	$61,400	$65,950	$70,500	$75,050
80% AMI	$63,700	$72,800	$81,900	$90,950	$98,250	$105,550	$112,800	$120,100

Looking at this chart, what is your household's total income for your household size ?

Below 50% Area Median Income (AMI)

Between 50% Area Median Income (AMI) and 80% Area Median Income( AMI)

Above 80% Area Median Income( AMI)