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Please use this form for additional request regarding Emergency Assistance Relief Program (EARP).
If you are inquirying about the status of your Rental Relief Application - do not continue - instead please email HSS@montgomerycountymd.gov
Who is completing this form?
Please list your name (i.e. the name of the applicant / head of household) exactly as it appears on your ID.
Have your address changed since you applied for benefits?
Home Address (ex: 401 Hungerford Dr, Rockville, MD 20850 -- if you have an apartment number, please list that in the next question instead)
Date of Birth
Did you apply as a single adult or as a household with multiple family members (i.e. children, partner, etc.).?
Please provide the name, date of birth, gender, and relationship for one (1) of your family members on your application.
If you were a single applicant - please only enter the Name fields
OTHER HOUSEHOLD MEMBER - Gender
OTHER HOUSEHOLD MEMBER - Date of Birth
Please upload all required documentation for your case to be assessed timely
Submit Document: Proof of Income - (letter from your employer)
Submit Document: Proof of residency - Lease or Rental Agreement (signed letter from person being rented from)
Submit Document: Child Relationship Verification (e.g. Birth Certificate, School Report Card, Doctor Visit Notification)
To protect your personal information - please submit an email with your personal ID (Driver License or Passport) to this email box: email@example.com
I request that my family be referred to Emergency Assistance for Residence Program (EARP) for emergency assistance. I attest that I am NOT eligible for Maryland unemployment insurance or for the federal stimulus payments administered by the IRS. I have NOT yet obtained or been referred to this emergency assistance by any other organization. I also confirm the accuracy of information entered above, including my household income, household composition, and County residency. I understand that my information will be entered in the Emergency Assistance Platform (EAP) and will be shared only with authorized EARP personnel. I further understand that I am responsible to inform my referring agency if my situation changes, such as my address or contact numbers.
I swear (or affirm) that all information on this application is true, correct and complete to the best of my ability, knowledge and belief.
NOTE: After you click on Submit - keep the receipt numbers for your records. You will be given the option of downloading a PDF version of your request - please download as you cannot access this application after submittal.