Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.The Petaluma Housing Resolution Fund offers short-and-medium term financial assistance to individuals and families currently experiencing homelessness within the City limits of Petaluma. Individuals and families must have experienced unsheltered homelessness within Petaluma City limits to meet basic program eligibility. This program offers assistance with housing-related expenses like security deposits, rent, and other expenses necessary to mitigate housing barriers. Housing location services and case management are also provided.Fill out application completely. Incomplete applications cannot be processed.Please note that upon submission of an application, further documentation will be required if you are determined eligible to receive assistance. Examples include: Photo IDs for all adults, Social Security Cards (or ITINs) for all family members, Proof of all income (3 current/consecutive paystubs, benefits award letter, etc.). Nonprofit Agency with whom You Are Working: *COTSRebuilding Together PetalumaPetaluma People Service CenterHomeFirstName and Contact Information of Employee / Case Manager you are Working with at Referring Agency: *FirstLastEmployee / Case Manager's Phone Number:Employee / Case Manager's Email:Is This An Emergency Check Request? *YesNoIs Applicant ERF Qualified on the South County By Names List? *YesNoIs Applicant a HomeFirst Landlord Recruitment Incentive Client? *YesNoApplicant SectionApplicant #1 (Head of Household): Name *FirstMiddleLastPhone Number: *Email: *Date: *Date of Birth (DOB): *SSN: *Have you already located housing? *YesNoIf yes, please provide the address. Please let us know whether you have been approved and any additional details about the housing you have located:# in Household: *Last known Zip Code: *A.) Since October 2024 have you or your household slept outside or in a vehicle close to or within the same area of at at least one other person, or while near the belongings of at least one other person? *YesNoB.) Was this area located within the city limits of Petaluma? *YesNoIf yes to either question A or B, please describe the location where you slept: *Have you or anyone in your household ever been evicted? *YesNoHave you or anyone in your household ever been in any of the following COTS programs? Mary Isaak Center *YesNoFamily Shelter *YesNoPeople's Village *YesNoHead of Household- Check ALL that apply to you: *Physical DisabilityDevelopmental Disability (including IEP)Chronic Health ConditionHIV/AIDSMental Health IssuesSubstance Abuse IssuesSurvivor of Domestic ViolenceCancer Patient / SurvivorDiabetesFormerly IncarceratedVaccinated for COVID-19Current health insurance companyServed in the militaryNoneHead of Household- Check One: *American Indian, Alaskan Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Other Pacific IslanderWhiteI don’t knowAre you also Hispanic/Latino? *YesNoOther Adult Member's SectionOther Adult's Name:FirstMiddleLastSSN:Phone Number:Email:Date of Birth (DOB): processed. you Nonprofit Other Adult Member- Check One:American Indian, Alaskan Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Other Pacific IslanderWhiteI don’t knowAre you also Hispanic/Latino?YesNoOther household members UNDER the age of 18Person 1: Name:FirstMiddleLastSSN:Date of Birth (DOB):Relationship to Head of Household:Check All That Apply:Physical DisabilityDevelopmental Disability (including IEP)Chronic Health ConditionHIV/AIDSMental Health IssuesSubstance Abuse IssuesCancer Patient/SurvivorDiabetesFormerly IncarceratedVaccinated for COVID-19Current health insurance companyServed in the militaryNonePerson 1- Check OneAmerican Indian, Alaskan Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Other Pacific IslanderWhiteI don’t knowPerson 1- Are you also Hispanic/Latino?YesNoPerson 2:Name:FirstMiddleLastSSN:Date of Birth (DOB):Relationship to Head of Household:Check All That Apply: Physical DisabilityDevelopmental Disability (including IEP)Chronic Health ConditionHIV/AIDSMental Health IssuesSubstance Abuse IssuesCancer Patient/SurvivorDiabetesFormerly IncarceratedVaccinated for COVID-19Current health insurance companyServed in the militaryNonePerson 2- Check One American Indian, Alaskan Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Other Pacific IslanderWhiteI don’t knowPerson 2- Are you also Hispanic/Latino?YesNoPerson 3:Name:FirstMiddleLastSSN:Date of Birth (DOB):Relationship to Head of Household:Check All That Apply:Physical DisabilityDevelopmental Disability (including IEP)Chronic Health ConditionHIV/AIDSMental Health IssuesSubstance Abuse IssuesCancer Patient/SurvivorDiabetesFormerly IncarceratedVaccinated for COVID-19Current health insurance companyServed in the militaryNonePerson 3- Check OneAmerican Indian, Alaskan Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Other Pacific IslanderWhiteI don’t knowPerson 3- Are you also Hispanic/Latino?YesNoPerson 4:Name:FirstMiddleLastSSN:Date of Birth (DOB):Relationship to Head of Household:Check All That Apply:Physical DisabilityDevelopmental Disability (including IEP)Chronic Health ConditionHIV/AIDSMental Health IssuesSubstance Abuse IssuesCancer Patient/SurvivorDiabetesFormerly IncarceratedVaccinated for COVID-19Current health insurance companyServed in the militaryNonePerson 4- Check OneAmerican Indian, Alaskan Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Other Pacific IslanderWhiteI don’t knowPerson 4- Are you also Hispanic/Latino?YesNoI/we certify this information is true and correct to the best of my/our knowledge. I/we understand that deliberately falsifying any answers could be grounds for exclusion from the program. I/we hereby authorize COTS to verify all the information provided to obtain all relevant information pertaining to me/us and my/our family. Head of Household signature: * Clear Signature Date of Submission: *Other Adult Member's signature: Clear Signature Date of Submission:If I’m accepted into COTS’ Housing Resolution Fund Program, I agree to COTS contacting me after services have been completed to check on housing stability *YesNoSubmit
