Initial Assessment for Program Entry
CMTX
(Only apply if you are seeking assistance for the CURRENT month as we do not have ANY funding for arrears)
CMTX
Client Name
*
First Name
Last Name
Date Called
*
-
Month
-
Day
Year
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name of Apartment
Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code
Assess the Following
Does your landlord/Apartment Complex accept 3rd party direct deposits? (If NO, please do not complete as we will not be able to assist you)
Yes
No
How long have you lived in your apartment, is it greater than 90 days?
*
Yes
No
Are you Collin County Resident
*
Yes
No
Do you have an eviction
*
Yes
No
Are you current on rent
*
Yes
No
Have you used this program in the last three years?
*
Yes
No
Do you owe rent for last month?
*
Yes
No
Is the lease in your name?
*
Yes
No
How many are in your household?
*
What is the amount of your rent?
*
What can you pay towards your rent?
*
How many bedrooms?
*
Are you currently employed?
*
Yes
No
What is your gross employement/UE benefits (income before taxes)?
*
Is that,
*
Weekly
Bi-Weekly
Monthly
What are your other income sources
SNAP
SSI/Disability
Child Support
Are you receiving assistance from any other agency
*
Yes
No
If yes, Who?
Reason you could not pay rent this month
Result
If you qualify you will be able to submit, if there is no Submit button you did not qualify.
Submit
Should be Empty: