REQUEST FORM FOR EMERGENCY RENTAL ASSISTANCE (ERA) MOBILE OUTREACH

This service is only available to organizations that work with vulnerable populations who are in need of rent, electric and/or utility assistance. The individuals/households receiving this service must meet the federal guidelines for ERA as well as the following criteria:

Lack computers or internet connection; or,
Lack the skills needed to use a computer; or
Have language barriers or developmental disabilities; or
Are facing other barriers that prevent them from accessing the online application portal for rental assistance.

Name of the Organization: *This question is required.

Address of the Organization: *This question is required.

First and Last Name of the Requestor: *This question is required.

Email Address: *This question is required. This question requires a valid email address.

Phone Number: *This question is required.

Day and Time Requested: *This question is required.

Projected Number of Individuals to be Served: *This question is required.

Other Comments:

E-mail Disclaimer:

Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.

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