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Rental Assistance Application

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Rental Assistance Inquiry Form for Faribault and Le Sueur Counties

Please note this is not an inquiry for “Emergency Rental Assistance”; this is a “long term” rental assistance program. In the event you are interested in emergency assistance in either County you will need to contact the County Specialist in each County for further assistance.

IMPORTANT NOTICE: As of October 1, 2014, MVAC will only be accepting and processing applications for applicants that are considered established residents of either Le Sueur or Faribault County. The only preference or priority that we offer is that of residency; to be eligible for this preference you must be an “established” resident of either Le Sueur or Faribault County at the time of application. The waiting list will be closed to non-resident applicants.

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Click only once on the “Submit” button at the bottom of the form to send. Fill out as much information as possible. Fields marked with a red asterisk (*) are required.

Household Information

Please leave this field empty.

 Own Rent Other

 Faribault Le Sueur

Sources of Income

 Salary or Wages Alimony/Child Support Social Security Self Employment Retirement/Pension MSA Other/Interest No Income General Assistance Reemployment Comp. TANF (AFDC, MFIP) SSI Food Stamps Housing Medical Aid/Asst. Veterans Benefits

Household Type

 Farm Migrant Seasonal Farm Worker

 Yes No

 Single Parent/Female Single Parent/Male Adults with children Single Person Adults only Other

Assets

 Yes No

 Yes No

 Yes No

 Yes No

Other Information

 Yes No

 Yes No

Questions or Comments

Data Privacy Rights Of Applicants For MVAC Programs

Under current Federal and State legislation your right to privacy is protected. MVAC is asking you to supply us with private information concerning you, your family, and household. By Law you do not have to provide this information. MVAC needs information about you to determine if you can get help from any program. Without information about your household, MVAC may not be able to help you and the help may be late or less than what you may be eligible to receive. The purpose for this information is to inform you of eligibility for all programs at MVAC. MVAC may use information to research, plan, and evaluate programs. Information is used in determining compliance with Federal and State regulations. MVAC will use this information to make statistical and demographic reports to different agencies and funding sources. Never will information that identifies you or any member of your household be revealed unless you give your written permission. MVAC will also use this information to develop a mailing list. MVAC will use the mailing list to update you on the programs and program changes. At no time will the mailing list be revealed to anyone outside MVAC. To ensure that you are being served properly, only MVAC Staff whose jobs require the information will have access to it.

MVAC may share this information with state and local welfare agencies, community based organizations, local and state public and private human service agencies, the Minnesota Department of Economic Security, the United States Department of Labor, the United States Department of Health and Human Services and state and local educational programs, as allowed by law.

This Agency will keep this information for three years from the last date updated with you or until program audits are complete. You have the right to review your records at any time to request changes.

 Yes No

 Yes No

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