Eviction Prevention Program Intake Form Eviction Prevention Program Intake Form Household Information Household Size * First Name * Middle Initial Last Name * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Phone Number * Enter your phone number Email Address * Enter your email Eviction Prevention Assistance Brief Description of Eviction Prevention Need max 500 characters Gross Monthly Income Prior to COVID-19 Number of Household members: * Number of Adult Household (over age of 18) members * Date of Last Payment to Landlord or Utility Company * Is your hardship due to COVID-19? * Yes No Are you an Anne Arundel County resident? * Yes No Is your rent currently subsidized? * Yes No Do you live or work in the following three zip codes: 21144; 21076; or 21077? * Yes No Are you currently receiving unemployment benefits? Yes No If yes, how much per week? * If no, why not Waiting for processing Not eligible If not eligible, why not? reCAPTCHA If you are human, leave this field blank. Δ