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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
    1$66,450
    2$79,950
    3$85,450
    4$94,900
    5$102,500
    6$110,100
    7$117,700
    8$125,300
  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.