Tarrant County Prevention Screening Form

Family Survey In Progress

This form will add a new member to the current family profile. If you have finished adding all family members, click the button to start over.

This assessment determines your eligibility for rental assistance. Please do not leave any portion of the assessment blank.

About You

First Name

This is required

Last Name

This is required

Address & Apartment Number

This is required

City

This is required

Do you live in any of the following cities: Arlington, Fort Worth, or Grand Prairie?

Yes

This is required

Please stop filling out this form and contact Tarrant County Human Services for assistance in your area, 817-531-5620.

Your Email

Enter a valid email address

Your Phone Number

Enter a valid 10-digit phone number

Your Date of Birth

For example: 3 27 2007

Month

must be a month (1-12)

Day

must be a day of the month (1-31)

Year

must be a four-digit year

Overview

Please note: Assessments will be evaluated for eligibility and completeness. Tenants will be notified or asked for additional requested items by email.

Tenants MUST NOT have received rental assistance from any other sources for which tenant is requesting at this time.

Is there a military veteran in the home?

Yes

This is required

If there is a military veteran in the home, please call Community Actions Partners first at 817-392-5780.

Have you received rental assistance within the past three (3) years?

Yes

This is required

Do you live in a unit assisted by another Federal Funded housing, such as Section 8?

Yes

This is required

Please explain current Household "Crisis" that has resulted in the non-Payment of rent for your household this month.

This is required

Have you ever been literally homeless (Stayed in an Emergency Shelter or Outside or a place not meant for habitation)?

Yes

This is required

Rental History

How many bedrooms is your unit?

This is required

Have you received a "3 Day Notice to Vacate" from your property management?

Yes

This is required

Have you been served by the Tarrant County Constable Office with a formal eviction court date?

Yes

This is required

How many people on the lease are over 18 years old?

This is required

How much is your base rent? (This does NOT include utilities or other incidentals.)

Landlord Name

Landlord Phone Number

Enter a valid 10-digit phone number

Landlord Email

Enter a valid email address

Income Details

Does the landlord have a relationship to anyone in the household?

Yes

This is required

Has any person or program assisted in paying rent for your household in past 12 months?

Yes

This is required

What is the GROSS Income per pay period or Monthly Income for household members over age 18?

What forms of income were received within the past 30 days? (All income sources will be counted. Proof of employment termination may be needed.)

SSI

SSDI

Veteran's Benefits

Food Stamps

Child Support

Unemployment

Did you lose employment or have lower income within the past 30 days?

Yes

This is required

Has anyone in your household received written notice that they will start receiving income and or state benefits? (Ex: Job offer letter, unemployment benefits, SNAP benefits, child support, etc.)

Yes

This is required

Applicant Certification

I/we understand that the above information is being collected to determine if I/we are eligible to receive rental assistance. I/we authorize the program administrator to verify all information provided on this assessment.