Commerce City Referral Form

This form is intended for the Commerce City Emergency Rental and Mortgage Assistance Program. You MUST reside in Commerce City.

Presione aquí para obtener una solicitud en español

Name of person making the referral
(If someone other than the Resident is completing this form)

Phone number of person making the referral

Email of person making the referral

Resident Information

First name*

Last name*

Preferred Name(s)

Date of birth*

Phone number*

Email*

Resident grants CEDP/CARE Center permission to text my phone number in response to my emergency rental assistance applications, with any updates for further communication about their Rental Assistance application/case. Standard messaging rates will apply. You may opt-out at any time by texting "STOP."

Are you a resident of Commerce City?

Yes

Street address*

City*

State/Region*

Zip code

County*

Preferred Language*

List all household members and birthdates*

Requested Assistance

Assistance Requested*

Rental Assistance /

Mortgage Assistance

Utility Assistance

Hardship: A hardship to qualify for these funds. Please select all that apply. (Documentation will be required for each hardship selected)*

Loss of Job. (Provide copy of termination letter)

Sudden medical issue for applicant or family member that results in a loss of income for more than 30 days. (Provide copy of medical bills)

Increase in property taxes of more than 25% in any tax year (if not paid with mortgage) and proof that no income is available for payment of taxes and failure to pay will result in foreclosure.

Death of spouse, domestic partner, or dependent. (Provide death certificate).

Fleeing domestic abuse.

Other- Please explain

Are you a renter or a homeowner?*

Renter

Homeowner

Mobile Homeowner with Lot Rent

Other

When did you receive your most recent Eviction Notice, Utility Past Due notice, or Mortgage Delinquency notice?*

Income: What is tenant's monthly household income? *

Demographic Information

What is racial identity of resident?*

Other or multi-race details (optional)

What is ethnicity of tenant?*

Non-Hispanic or Non-Latin(a)(o)(x)

Hispanic or Latin(a)(o)(x)

Prefer not to Answer

Please select all that apply*

One or more household members has a disability

One or more household members is 62 years old or older

Household is currently experiencing homelessness

One or more household members is on active duty or a military veteran

Is there minor children in household

Has primary applicant been unemployed for 90 days or more

None of the above

What are the the resident's preferred pronouns?*

Required Documents

REQUIRED Upload:
- Eviction Notice (Demand, Summons and Complaint, Writ of Restitution, Stipulation or Sheriff's Notice
AND
- ID for primary applicant

Once the application is assigned to a reviewer, additional documentation will be required. If available, please upload here.

Rental Assistance/Relocation Assistance
- ID's for all adults over 18-years old
- Income verification (last 30 days)
- Current Lease
- Ledger
- Landlord's W9
- Additional documentation

Mortgage Assistance
- ID's for all adults over 18-years old
- Mortgage statement(s)
- Proof of Income*

Additional Information

Anything else we should know, such as assistance requested, eviction court status or deadline, or unique circumstances of this application.*

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