Burlington County CARES ACT Application

Preliminary Application for Burlington County CARES Act Mortgage/Utility Assistance Program

Please select which type of assistance you are applying for.

Please provide the following information about your household:

First Name

Last Name

Street Address (including unit # if applicable)

City

State

Zip Code

County

Phone Number

Alternate Phone

Alternate Phone Type

How many people live in your household?

What is the gross annual income combined for all adult household members (enter 0 if none)?

Income includes, but is not limited to: Gross wages, salaries, tips, commissions, overtime, alimony, child support, pensions, and social security, unemployment and disability benefits.

If you do not want to provide your gross annual income at this time, is your total gross annual income of all adult household members combined less than income listed for your household size on this program flyer?

Are you a home-owner or a renter?

Is the unit your full-time, year round residence?

Was the mortgage bill paid up-to-date as of March 1, 2020?

Are the property taxes for this home paid up to date?

Do you have an active bankruptcy?

Do you receive federal assistance?

How did you hear about Program?

Signature

I certify that the information provided herein is true and complete and that any misrepresentation of income or household size reported herein may be cause for program disqualification. I also understand that this information is to be used only for determining my preliminary eligibility and does not obligate me in any way.

E-Signature

Submission Date

You will receive notification that your Preliminary Application was successfully submitted. If you do not receive this notification, please resubmit your Preliminary Application.

Contact Information