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

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.
 
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?
If back-rent is owed, how much do you owe?
Can you afford to pay full rent going forward beginning July 1, 2021?
 
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?
 
Has your landlord threatened eviction?
 

Get Your Needs Met!

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.

Questions and Concerns

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