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Housing Search Workshops
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Homeownership
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Get The Lead Out Program
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Municipalities
HCEC Intake Form
Home
News
Calendar
About HRA
Board of Commissioners
Public Notice & Public Records
Public Procurement
RAFT/ERMA Emergency Assistance
RAFT & ERMA Emergency Rental Assistance
Homelessness
Foreclosure Prevention
Rental Assistance
Section 8 Housing Choice Voucher Program
Family Self-Sufficiency Program
Massachusetts Rental Voucher Program
Information for Landlords
Find Housing
Public Housing for Families
Public Housing for Seniors and Persons With Disabilities
Other Affordable Rental Housing
Housing Search Workshops
Apartments Available Now
Education
Financial Education
First Time Homebuyer Workshops
Good Tenant Workshops
Housing Search Workshops
Landlord Resources
One-on-One Housing Counseling
Tenant Resources
Homeownership
Leverett Assistance Programs
Housing Rehabilitation Programs
Get The Lead Out Program
Foreclosure Prevention
Affordable housing for sale
Municipalities
HCEC Intake Form
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Personal Information
First Name
Last Name
Who referred you/how did you hear about us?
Contact Info
date_time
id
Address
City
Ashfield
Bernardston
Buckland
Charlemont
Colrain
Conway
Deerfield
Erving
Gill
Greenfield
Hawley
Heath
Leverett
Leyden
Millers Falls
Monroe
Montague
New Salem
Northfield
Orange
Rowe
Shelburne
Shelburne Falls
Shutesbury
South Deerfield
Sunderland
Turners Falls
Warwick
Wendell
Whately
Applying to live in Franklin County
ZIP Code
Home Phone
Cell Phone
Work Phone
Email
Alternative Contact Name
Alternative Contact Phone Number
Date of Birth
Gender
Female
Male
Transgender
Would you like to be added to the FCRHRA tenant list serve?
yes
no
What brings you here today? (please check all that apply)
AT RISK OF HOMELESSNESS
I have been denied emergency assistance
I have a notice to quit
I am living doubled-up. I have to move out.
I owe rent and am being evicted
My landlord is being foreclosed upon. I need to move out.
My apartment is in poor condition. I have to move out.
I am a few/many months behind on my mortgage.
HOUSING SEARCH
I need help finding a permanent place to live
I stay in a shelter at night
I live on the street. I need help finding housing
I want to talk about how to get a subsidy
FAIR HOUSING
I feel that I have been discriminated against for housing.
I have been denied housing.
OTHER
I pay 50% or more of my income to my housing costs
I need help making my apartment/home accessible for a disabled family member
I want to buy a house and would like to learn more about how to do that
I need some help to deal with my landlord to get repairs made to my apartment
I am behind on utility bills and I have shut off notices
I am having issues with my landlord-property management issues
I am a landlord having issues with a tenant
I am a victim of domestic violence
Do you have a subsidy or live in public housing?
What is your goal?
Are you working with any other agencies? (please list)
Household Composition
What is your preferred language?
Number of Children
Other languages spoken at home
Are you a...
Tenant
Homeowner
Homebuyer
Homeless
Advocate/Agency
Rental Property Owner
Other (please use "+" button to list)
Number of Adults
Do you have at least one child under 21 living with you?
Yes
No
Ages of Children
Are you Pregnant?
yes
no
Does anyone in your household have a disability?
No
Myself
Family member
Income and Expenses
Source(s) of income & benefits
Wages
TAFDC/EADC
Food Stamps/WIC
SSI/SSDI
TANF: Trans/Childcare
Alimony
Unemployment
Child Support
CHIP
Retirement/Pension
Refugee Stipend
Veterans Benefits
Medicare/Medicaid
Fuel Assistance
No income
Other (please use + button to list)
Add a new option to those above
Monthly Income gross before taxes
Monthly Rent/Mortgage Payment
Additional Information
Education Level
None
Elementary School
High School Diploma/GED
Vocational School
College
Post Graduate
Have you ever served on active duty in the military?
yes
no
not sure
If yes, which branch?
Coast Guard
Army
Air Force
Navy
Marines
National Guard
Other(please list)
Ethnicity
Not Hispanic
Hispanic
Race
American Indian/Alaskan
Asian
Black/African American
Native American/Alaskan Native
White
Choose not to respond
Other (please use "+" button to list)
Add a new option to those above
Submit
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