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Behind on Rent Inquiry Form

  1. Town Seal
    Emergency Rental Assistance Program
  2. If you need assistance filling out the Emergency Rental Assistance Program application, enter your information below and a representative will contact you.
  3. Do you rent a house or apartment in the Town of Brookhaven?
  4. Was your pre COVID gross household income with in the limits below?
  5. Family SizeMaximum Income
  6. Did you pay all your rent through March 2020?
  7. Do you receive any housing subsides such as Section Eight?
  8. Has there been a loss of income in your household due to COVID-19?
  9. Do you have any past due utilities?
  10. Do you need assistance filling out the on-line application?
  11. Leave This Blank:

  12. This field is not part of the form submission.