First Name *

Middle Name

Last Name *

Gender * Male Female Do Not Prefer

Date of Birth *

Marital Status * Single Married

Race * American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Ethnicity * Hispanic or Latino Non Hispanic or Latino

Person with Disability *

Yes
No

Email Address *

Mobile Phone Number *

Alt. number

Social Security Number *

Are you an employee or contractor of Fort Bend County? *

Yes
No

Are you able to pay your current months' rent? *

Yes
No

Based upon your current outlook, will you be able to pay next months’ rent? NOTE: This does not impact your eligibility for assistance.

Yes
No

Did you experience financial hardship related to COVID-19? *

Yes
No

If so, how?

Street Address 1 *

Street Address 2 (Ste. Apt. etc.)

City * Arcola Beasley Cinco Ranch Cumings Fairchilds Fifth Street Four Corners Fresno Fulshear Houston Katy Kendleton Meadows Place Mission Bend Missouri City Needville Orchard Pearland Pecan Grove Pleak Richmond Rosenberg Simonton Stafford Sugar Land Thompsons Weston Lakes

State * Texas

Zip Code * 77053 77083 77406 77407 77417 77441 77444 77451 77459 77461 77464 77469 77471 77476 77477 77478 77479 77481 77487 77489 77494 77496 77497 77498 77545

Landlord/Property Manager Name

Phone Number

Email

What type of assistance are you in need of? * Rental Utilities Both

If Utilities are needed, check all that apply * None Electricity Gas Internet Trash Water

Use Ctrl+click to select multiple items

Have you applied or received rental assistance due to COVID-19 from this program before? *

Yes
No

Have you received rental assistance from any state or local government program? *

Yes
No

Provide details on the assistance you have received

Number of household occupants including yourself *

Household Members (including yourself)

Total Household Income as of April 30, 2025.

What is your current employment status? Employed Unemployed Temporary

Are you past due on rent? *

Yes
No

Past rent due amount

Past rent due in months

Monthly rent/lease amount

Utilities

By checking the following agreement and submitting this online form, I/WE, THE UNDERSIGNED, HEREBY CERTIFY AND ATTEST TO THE FACT THAT ALL OF THE INFORMATION I HAVE PROVIDED ABOVE IS ACCURATE AND NOT FALSELY PROVIDED. FALSELY PROVIDED INFORMATION WILL RESULTE IN REJECTION OF THE APPLICATION AND DENIAL OF ANY PARTICIPATION IN THE PROGRAM. FALSIFYING INFORMATION MAY ALSO RESULT IN PROSECUTION FOR VIOLATION OF FEDERAL LAW FOR MISSTATING, MISREPRESENTING ANY SUCH INFORMATION PER TITLE 18 U.S.C § 1001 (FALSE STATEMENTS, CONCEALMENT).

I/we understand that the information submitted will be verified prior to approval.

I agree to the terms and conditions.*

Electronic Signature (full name) *

I agree to notify Fort Bend County within five (5) business days of any discrepancies on the wages I am reporting for this program. Further, I understand and acknowledge The County's right and responsibility to recapture all or a portion of the ERA2 Rental Assistance award I may be awarded should the information I have provided is false and fraudulent under penalty of law.

I agree.*