1

Application

 *

Application

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

2

Property Owners Information

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Property Owners Information

Property Owner’s Legal Name	Property Owner’s Phone Numberext.	Property Owner’s Email Address
Household Size	Gross Household Income (Dollars)	Number of Residents 18 years and older

3

Please describe the needed home or property repair:

Please describe the needed home or property repair:

4

Check All That Apply

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Check All That Apply

	Yes	No
Have you used this program in the past 12-months?	Check All That Apply	Check All That Apply
Are you applying due to a financial hardship?	Check All That Apply	Check All That Apply
Have you been unemployed for more than 90-days?	Check All That Apply	Check All That Apply

5

 Please describe your financial hardship and eligibility for this program:

Please describe your financial hardship and eligibility for this program:

6

Are you the sole lease/title holder in the household?

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Are you the sole lease/title holder in the household?(Select an Answer) Yes No

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Qualifying Hardship

• Loss of Job
• Sudden medical issue that results in loss of income for more than 30 days
• <100% Area Median Income

Required Documentation:

• Application
• Photo ID for every household member aged 18 and older
• Proof of income is required for household members over the age of 18* (please provide each of the following):
  
  • Copies of two most recent pay stubs
  • Copy of homeowners insurance 
  • Copy of mortgage statement
  • Copies of two most recent bank statements
  • Payments from other benefits program
  • Loss of Job (if applicable, provide a copy of the termination letter)
  • Documentation of sudden medical issues that prevent residents from earning an income (if applicable)
  • Documentation of ZERO income (if applicable)
  • Copy of property tax statement
  • Copy of all current utility bills
  • Most recent W-2 form

7

If you cannot provide documentation, provide information to justify why that information is not available:

If you cannot provide documentation, provide information to justify why that information is not available:

8

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

 *

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

Required Documentation 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

Required Documentation 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

Required Documentation 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

Required Documentation 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

Required Documentation 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

Required Documentation 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

Required Documentation 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

Required Documentation 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

Required Documentation 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

Required Documentation 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

Required Documentation 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

9

To be considered for assistance, all applicants must complete the application in full and provide supporting verification documents. Incomplete applications or missing documentation may result in delays or denial of assistance.

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To be considered for assistance, all applicants must complete the application in full and provide supporting verification documents. Incomplete applications or missing documentation may result in delays or denial of assistance.(Select an Answer) I self-certify that the information on this application and my supporting documents are accurate and truthful under penalty of perjury under the laws of the State of Colorado.

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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.

10

Ethnicity, please select all that apply:

Ethnicity, please select all that apply:

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: If other, type text here.

11

Gender

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

12

Age of applicant

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

13

Primary language spoken

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

14

Have you served or are you currently serving in the U.S. Military? 

Have you served or are you currently serving in the U.S. Military? (Select an Answer) No Military Service Military Reserves Veteran/Past or Current Experience Prefer not to say

15

Do you identify as a member of the Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQIA+) Community?

Do you identify as a member of the Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQIA+) Community? (Select an Answer) Yes No Prefer not to say

16

What is the highest level of education you have completed?

What is the highest level of education you have completed? (Select an Answer) Less than High School Some High School High School Graduate Some College College Graduate Post Graduate Degree Prefer not to say

17

Do you have a disability?

Do you have a disability? (Select an Answer) Yes No Prefer not to say

18

Are there any individuals in the household, other than the applicant, who (check any/all statements that are true):

Are there any individuals in the household, other than the applicant, who (check any/all statements that are true):

Are dependents under the age of 18

Have a disability

Are over 65 years of age

Are past or current U.S. Military

Identify as a member of the Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQIA+) community

I do not know

Prefer not to say

None of the above

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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