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