Commonwealth of Massachusetts
Emergency Rental Assistance 2022-2023
Tenant Name ________________________
Address _____________________________
City, State, Zip code _________________ ____________________ _________________
Phone / Email __________________ ____________________________________________
SSN/DOB ______________ _____________
Initial ___________________
.
Landlord Name _______________________
Address _____________________________________________________________________
City, State, Zip code __________________ _________________ ____________________
Phone / Email ______________ _______________________________________________________________
Monthly Rent _________________________
Rent in Arrears _______________________
Reason for arrearage
Loss of Job _______________________
Medical __________________
Psychological __________________________
please specify_____________________
.
Application to for Assistance
City/Town/State _________________________
Veterans Administration __________
Church ____________________________
Synagogue _______________________
Mosque ___________________________
RAFT Program ____________________
Section 8 _________________________
Filing with Housing Court _______________ ______________________
©2023