FSU Pre-Intake Interview Sheet

Our Rental Assistance portal is open on the 2nd Tuesday of each month from 8:30 AM to 5:00 PM. Please, submit your request during these hours for the best chance of receiving rental support. If you need assistance with food, utilities, or clothing, there’s no need to use the portal, call us at 585-288-0021 (Monday–Friday, 8:30 AM–5:00 PM), and we’ll be happy to assist you.

KNOW YOUR RIGHTS: Facing immediate eviction? Support is available.
Visit TenantDefense.org or call (585) 504-6195 for resources and assistance.

ADDITIONAL COMMUNITY RESOURCES:

MyWayfinder
2-1-1 Lifeline –
Visit online or call 2-1-1 or 1-877-356-9211
Emergency Rental Assistance – Apply through the Department of Human Services (DHS) at mybenefits.ny.gov
Please note that funds are limited, and submitting a request does not guarantee assistance. We encourage you to explore other funding options as well. Our team will do our best to notify you of a decision within 14 business days.

Applicant Informaion

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

*Note: Either a phone number or email address where applicant can be reached must be provided. If applicant does not have access to their own, please provide a phone number or email address where the applicant wishes to be reached.

Email

*Note: Either a phone number or email address where applicant can be reached must be provided. If applicant does not have access to their own, please provide a phone number or email address where the applicant wishes to be reached.

Number of People in Your Household

Household income – Employment

How often do you get paid?

When you get paid, what is your gross pay (this is before taxes)?

Household income – Other (DHS, Social Security, SSI, etc.)

How often do you receive this income?

If applicable, how much do you receive?

about your Needed

What type of rental assistance do you need help with?

First Month Rent (yes/no), Amount Needed

First

Last

Security Deposit (yes/no), Amount Needed

First

Last

Back Rent (yes/no), Amount Needed

First

Last

If you are requesting back rent, please answer the following:

How much rent do you pay per month?

How many months do you owe?

Reason for not paying:

Have you received rental assistance in past 12 months?

Please provide the following for your landlord:

Name

First

Last

Phone

Email

How did you hear about us?

Applicant Informaion

Household income – Employment

Household income – Other (DHS, Social Security, SSI, etc.)

What type of rental assistance do you need help with?

Please provide the following for your landlord:

contact

contact