Are you at risk of losing your housing?

Safe, stable and dignified housing is a human right. Fill out this short questionnaire to help inform the housing policies we will advocate for and tell lawmakers what they need to do to protect your housing.

Contact Information

First Name

Last Name

Email

Phone Number

Address

Zip Code *

What county do you reside in? *

Optional Demographic Questions

Do any of these describe your household? — please check all that apply

How do you describe your race/ethnicity? — please check all that apply

Eviction Risk

Are you working now? Please check all that apply and enter the type of job you held or hold.

I was laid off from my job permanently

I am temporarily laid off or furloughed

My hours were reduced because of the pandemic

I was not working before the pandemic

I am working the same job and hours as before the pandemic

My former employer decided not to reopen or filed bankruptcy

Me or someone in my household has experienced health related conditions that have impacted our ability to work

Other Other

If you lost your job or your workplace closed, do you think your job will come back in 2021?

Do you have any back-rent that has built up?

Yes

No

I'm not sure

If back-rent is owed, how much do you owe?

Can you afford to pay full rent going forward beginning July 1, 2021?

I cannot afford rent going forward

I may be able to pay rent, but will have to cut spending on other necessities (such as food, health care/medicine, transportation, etc.)

I will be able to pay rent

I'm not sure

Other Other

How likely are you to afford a 2nd monthly rent payment starting July 1st 2021, covering back-rents after the eviction moratorium ends on June 30, 2021?

This would not be possible

I may be able to pay this, but it would be an extreme burden

My ability to pay depends on if I am able to be fully employed

I can afford to pay 2 months of rent on July

I'm not sure

Other Other

Has your landlord threatened eviction?

Yes

No

I'm not sure

Other Other

Get Your Needs Met!

Are you feeling stress and anxiety because, through no fault of your own, YOU and MEMBERS of your HOUSEHOLD may SOON be facing EVICTION? If yes, please comment below and/or record a video of yourself telling lawmakers what they need to do to make sure you have stable and dignified housing.

You can record video testimony and decide how you would like to use the video below.

If you are on a mobile phone, make sure to click "2. Upload" after recording.

After submitting this form, the next page provides an easy way to send it to lawmakers.

Video length is limited to 5 minutes. Here is a suggested format for your video:

Start by introducing yourself (who you are, what you do, and where you live)

Explain your housing situation (such as who you live with and any challenges you've have paying rent or accessing the housing you need)

Tell them what you need (Examples: "I need help paying my back rent" ; "I cannot afford to pay over half of my income on housing" ; "I lost my job and I don't know how I will pay rent in the future")

Explain what will happen to you if they fail to act (Examples: "We will lose our home and end up on the street"; "With an eviction on our record, it will make it difficult for us to rent again")

End with an affirmational message (Example: "I'm counting on your leadership to help me and my family to stay in our home")

How would you like to use this video?

You own the rights to your video, and may allow Organization Name(s) to use your video in it's advocacy work.

If your video contains offensive or inappropriate content, the link to your video will be turned off and we will send you an email explaining why it has been removed.

I'd like to email it to lawmakers

I'd like East County Rising and the Community Alliance of Tenants to use it in its advocacy work

I'd like East County Rising and the Community Alliance of Tenants to combine it with other videos and post it on YouTube and it's website

Questions and Concerns

Do you have any questions, or is there anything else you'd like us to know?

0/255 characters