AHAP Online Application

"*" indicates required fields

Applicant Information

Name*

First Middle Last

Today's Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Amount of funds you are seeking:*

Funds will be utilized toward:*

Rent/Mortgage

Utilities

Pest Eradication

Vehicle Repairs

Required Information

Landlord Name

First Last

Landlord Phone:

Please attach a copy of your lease

Max. file size: 100 MB.

Please attach Proof of Need from landlord

Max. file size: 100 MB.

Utility Company:

Utility Account Number

Please attach a copy of your most recent bill

Max. file size: 100 MB.

Have you been sent to a consumer's home where bed bugs were known to be a problem?

Yes

Please attach a copy of your vehicle registration

Max. file size: 100 MB.

Household Information

How many adults in household:*

How many children in household:*

Proof of annual income for entire household:*

Drop files here or

Max. file size: 100 MB.

You can upload multiple files here, to reflect multiple incomes within the household

Additional Information

Please describe fully why you are in need of financial assistance (tell your story) here:*

Name of PAS Supervisor (this is a VFI PAS Supervisor who is aware of my current financial situation and can assist in processing my application by signing off on my story):

Disclaimer and Signature

Consent*

I agree with the statement below

I certify that my answers are true and complete to the best of my knowledge. If this application leads to payment, I understand that false or misleading information in my application will result in the loss of my ability to apply for help in the future. I have also read and fully understand the AHAP description page, which preceded this application, explaining the AHAP requirements and expectations.

This field is for validation purposes and should be left unchanged.