1

Application

 *

Application

First Name	Last Name	Date
Street Address	City	Zip Code
Email	Phoneext.

2

Information

 *

Information

Number of residents 18 years and older?	Gross Household Income ($)
Do you own or rent?	Property Owners Name
Property Owners Phoneext.

3

Were you issued a code violation?

 *

Were you issued a code violation?(Select an Answer) Yes No

4

Violation Information

Violation Information

Violation Number	Compliance Date
Violation Type

5

 

 *

	Yes	No
Have you used this program in the past 12-months?	Answer	Answer
Are you applying due to a financial hardship?	Answer	Answer
Do you have a disability that prevents compliance?	Answer	Answer
Have you been unemployed for more than 90-days?	Answer	Answer

6

Qualifying Hardship

 *

Qualifying Hardship(Select an Answer) Loss of Job Sudden medical issue that results in loss of income for more than 30 days Age or Disability that prevents resident(s) from achieving compliance <80% Area Median Income

7

Please describe your hardship:

 *

Please describe your hardship:

---

Required Documentation
(Please provide documentation based on qualifying hardship)

• This application
• Photo ID for every household member age 18 and older
• Proof of Income (please provide one of the following)
  • Current pay stub
  • Most recent tax return
  • Bank statements
  • Payments from other benefits program
• Documentation of ZERO income
  • If you cannot provide documentation, provide information to justify why that information is
    not available
•  Proof of Disability
  • Physical
  • Age
  • Other
• Loss of job. Provide copy of termination letter
• Documentation of sudden medical issue that prevents resident from earning an income

To be considered for assistance, all applicants must complete the application in full and provide supporting verification documents (such as proof of income, residency, and copies of the code violation notice).

Incomplete applications or missing documentation may result in delays or denial of assistance.

8

File Upload
(Please label files appropriately and combine files where possible) 

 *

File Upload (Please label files appropriately and combine files where possible)

File Upload (Please label files appropriately and combine files where possible) Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

File Upload (Please label files appropriately and combine files where possible) Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

File Upload (Please label files appropriately and combine files where possible) Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

File Upload (Please label files appropriately and combine files where possible) Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

File Upload (Please label files appropriately and combine files where possible) Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

---

Demographic Information (Optional)

Commerce City values diversity and inclusion. The following questions are optional and will not affect your eligibility for assistance. This information helps us better understand and serve our community.

9

Please select all that apply:

Please select all that apply:(Select an Answer) First Nation/ American Indian/ Indigenous Alaska Native Asian, Asian American or South Asian Black or African American Hispanic or Latino/a Middle Eastern/North African Pacific Islander White/European American I prefer not to answer Other:

10

Gender

Gender(Select an Answer) Male Female Non-binary Prefer not to say

11

Age of applicant

Age of applicant(Select an Answer) 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 64 and older

12

Primary language spoken

Primary language spoken(Select an Answer) English Spanish Other (Please specify)

Page 1 / 1