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* 1. Has your household experienced a loss of income due to COVID-19 impacts?

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* 2. Do you pay rent for your housing or a mortgage?

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* 3. Number of people in household who have lost income?

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* 4. What is the monthly dollar amount that your household has lost due to the COVID emergency?

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* 5. Please describe the reason for loss of income. (Ex. Laid off, hours reduced, positive diagnosis requiring quarantine, self-quarantine, caring for child whose school is closed)

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* 6. How much of April’s rent or mortgage will you be paying?

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* 7. Were you on a payment plan for your rent or mortgage prior to April 2020?

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* 8. Other than rent or mortgage, what other bills are you having difficulty paying this month?

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* 9. If you are interested in being contacted or receiving COVID related resources, please fill out the following contact information.

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* 11. Is there anything else you'd like us to know?

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