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Application Form

Full Name

Date of Birth

Phone Number

Email Address

Address

Preferred Language

If you selected "Other", please specify your language:

Household Size

Number of Adults in Household

Number of Children under 18

Household/Parent Situation

Disability in the Household-Optional

if yes,

Approximate Household Monthly Income ($)

Sources of Income

Employment/Self employment SSI/Disability Government benefits -Calfresh/Calwork other

Current Housing Situation

Monthly Rent or Mortgage Payment ($)

Program Understanding: Accepted

I understand that AssistMyHome reviews applications in accordance with its policies and program requirements. If selected, I may be considered for an AssistMyHome Housing Assistance Campaign.

Information Accuracy: Accepted

I declare that all information provided is true and accurate to the best of my knowledge. I understand that, if selected, I may be required to provide supporting documentation to verify the information submitted in this application.

Terms & Conditions: Accepted

I have read, understood and agree to AssistMyHome's Policies and Terms & Conditions.

Communication Consent: Accepted

I agree to receive updates and communications from AssistMyHome, including informational and promotional messages.