City of Frisco 
COVID-19 Emergency Rental & Utility Assistance
Screening Form


If you reside in the City of Frisco and your household is impacted, please complete the following form.
Only one submission is needed. Multiple submissions will not help us to process your application faster.


Si reside en la ciudad de Frisco y su hogar se ve afectado, complete el siguiente formulario. 
Solo se necesita una presentación. Varias presentaciones no nos ayudarán a procesar su solicitud más rápido.

Are you a resident of the City of Frisco? / ¿Es residente de la ciudad de Frisco?*


Name (Head of Household) / Nombre de la Cabeza de la Familia*
Race (Head of Household) / Raza (cabeza de familia)*
Ethnicity (Head of Household) / Etnia (cabeza de familia)*
Name of Adult 2 / Nombre del adulto 2*
Name of Adult 3 / Nombre del adulto 3*
Name of Adult 4 / Nombre del adulto 4*
Name of Adult 5 / Nombre del adulto 5*

Address 

Address is limited to City of Frisco  |  La dirección se limita a la ciudad de Frisco

Ex. 1132
Ex. Main Street

Head of Household's Date of Birth / Fecha de nacimiento del jefe de familia*


Has one or more members of your household experienced a reduction in household income, incurred significant costs, or experienced other financial hardship due, directly or indirectly, to the COVID-19 outbreak? / ¿Uno o más miembros de su hogar ha experimentado una reducción en los ingresos del hogar, ha incurrido en costos significativos o ha experimentado otras dificultades financieras debido, directa o indirectamente, al brote de COVID-19?*
$
$
Are you renting or do you own your home? /¿Está alquilando o eres dueño?*
$
When is your next payment due? / ¿Cuándo es su próximo pago?*
Employment Status / Estado de Empleo*
Have you filed for unemployment? / ¿Has solicitado desempleo?*
Are you receiving unemployment? / ¿Estás recibiendo desempleo?*
Use your mouse or finger to draw your signature above

Document Upload /  Subir Documento

Several of the following documents are required for your application to be processed. They are marked with a red star. Your application will not be submitted without them. 

Se requieren varios de los siguientes documentos para que se procese su solicitud. Están marcados con una estrella roja. Su solicitud no se enviará sin ellos.

No File Chosen
File uploads may not work on some mobile devices.
Driver’s License or State ID for applicant and co-applicant / Licencia de conducir o identificación estatal del solicitante y cosolicitante
No File Chosen
File uploads may not work on some mobile devices.
Furlough letter or layoff letter, unemployment filing, loss of income documentation, etc / Carta de licencia o carta de despido, declaración de desempleo, documentación de pérdida de ingresos, etc.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
Which of the following utilities are you requesting assistance for? / ¿Para cuál de las siguientes empresas de servicios públicos solicita asistencia?
Check all that apply / Marque todo lo que corresponda
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

Additional Documents /  Documentos adicionales


No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

This form is limited to City of Frisco residents. Please refer to your local jurisdiction for assistance. 

Este formulario está limitado a los residentes de la Ciudad de Frisco. Consulte su jurisdicción local para obtener ayuda. 

Reviewer Information

Started Processing Application
:  
If applicant earns more than the current AMI based on all cources of income, can they provide a Tax Return for 202 which shows an Adjusted Gross Income?
Name, phone number, email, etc.
Has landlord been contact?
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

Payment Information

Client Name
ex. March, April, May

Payment Amounts

$
$
$
$
$

Rent Mailing Information

Pay to
Address

Electric Mailing Information

Pay to
Address

Gas Mailing Information

Pay to
Address

Water Mailing Information

Pay to
Address

Other Mailing Information

Pay to
Address

Program Manager Approval

Approved by Program Manager for payment*

FOR ACCOUNTING USE ONLY -- Rent Payments

Check Date
Date Cleared Bank

FOR ACCOUNTING USE ONLY -- Electric Payments

Check Date
Date Cleared Bank

FOR ACCOUNTING USE ONLY -- Gas Payments

Check Date
Date Cleared Bank

FOR ACCOUNTING USE ONLY -- Water Payments

Check Date
Date Cleared Bank

FOR ACCOUNTING USE ONLY -- Other Payments

Check Date
Date Cleared Bank
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