Somerville Office of Housing Stability Referral Form

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Somerville Office of Housing Stability Referral Form
The City of Somerville Office of Housing Stability (OHS) accepts referrals and requests for information and assistance to address housing issues impacting Somerville residents, and in limited cases, persons recently displaced from Somerville who lack a stable living situation.

Please complete this form as best you can, and then click SUBMIT. OHS staff will attempt to contact the person needing assistance within 1-2 business days of your submission.
Name of Person Needing / Seeking Assistance*

First & Middle Name(s)Last Name(s)
Phone Number (Numbers Only)*
Enter all 9s if phone number is unknown/unavailable, AND please provide alternate contact information in the "case summary" field: a working phone or email for a friend, family/household member, or provider who can reach the person needing assistance.Format: (000) 000-0000.
Email
Type "Not Used" if email is not used. Type "Unknown" if you don't know the email address.
Is email regularly checked for messages?

YesNoDon't know
Pronouns of the person seeking assistance

She / HerHe / HimThey / ThemOther: Please type pronouns here
Current Living Situation (Select option that best describes situation)*

Own a home/condo in SomervilleRent or share an apartment or room in SomervilleRent a room in Somerville from another tenantRecently displaced; in temporary living situation IN SomervilleRecently displaced; in temporary living situation NOT in SomervilleHomeless / UnhousedOther
Street Address with apartment number (e.g., #101, #2F) or location (e.g., basement, 2nd floor)*
Use N/A if address is unknown.
City and Zip Code (if known) of Current Living Situation*

Somerville 02143Somerville 02144Somerville 02145SomervilleOther
Is person needing assistance being evicted or pressured to leave?*

Tenant received WRITTEN Notice to Quit (NTQ) from landlordTenant received Court Notice ("Summons & Complaint") of intent to evictCourt decided eviction case against tenant, who will have to moveTenant received 48-Hour Notice to Vacate, served by ConstableLandlord has VERBALLY ordered tenant to leaveLandlord has THREATENED to evict tenant, but has not acted on threatOther tenants have TOLD tenant to leaveHomeowner facing foreclosure in primary residenceTenant living in property that is being foreclosed on by bankNone of the above: NOT facing eviction or pressure to leaveDon't know.Other
Date of Most Recent Notice / Court Document

MonthDayYear
Date of NTQ - or - "Entry Date" in bottom right of Summons & Complaint - or - Date of Court Judgment
When landlord sent Notice to Quit, did landlord also provide tenant with written information about tenant's rights and resources to avert eviction? (Documents required by City Ordinance - in English and other languages - can be viewed or downloaded from the OHS website at www.somervilleMA.gov/OHS).

YesNoDon't know
Primary language(s) spoken by person needing / seeking assistance*

EnglishSpanishPortugueseHaitian CreoleNepaliArabicHindiAmharicCantoneseMandarinVietnameseNot sureOther
Language Code
Is person needing / seeking assistance able to adequately and comfortably converse in English?*

YesNo, but has a friend, family member, or provider who can interpret / translateNo. Needs / seeks interpreter supportUnsure
Interpreter's Name (and relationship)
Interpreter's phone / email (if known)
Type of help needed / sought (select no more than 5)*

A. Assistance paying overdue rent ("arrears")B. Assistance paying the rent for the next few monthsC. Assistance paying overdue mortgage on current residenceD. Help preventing evictionE. Help preventing foreclosure on current residenceF. Help applying for affordable ("subsidized") housing or a Section 8 voucherG. Housing Search: help finding "mainstream" housing -- an apartment or room or roommate situation -- that's affordableH. Help recertifying eligibility for subsidized housing or a housing subsidyI. Help paying overdue utility bills (gas / electric) to prevent shutoffJ. Help with moving and/or tenancy start-up costsK. Help resolving a conflict with the landlordL. Help resolving conflict(s) with other tenantsM. Help addressing housing discriminationN. Help addressing unsafe / unhealthy conditionsOther
Brief summary of issues and help sought*
Number of persons in household
Separately indicate the number of adults (18 or older) and children (0-17)
Does household include any of the following? (select all that apply)

A. Senior Citizen(s) (age 60+)B. Person(s) with a DisabilityC. Infants or pre-school-age childrenD. Children in Somerville childcare or schoolsE. U.S. Military Veterans and/or their dependentsF. None of the Above
Race and Ethnicity of Household Member(s) (select all that apply)

African American / Black / AfricanAsian / Pacific IslanderCaucasian / WhiteNative American / Alaska NativeMulti-RacialHispanic / Latino(a)NOT Hispanic / NOT Latino(a)Other
Country of Origin / National Identity of Household Member(s)
Include ALL that apply to members of the household
Household's Current Gross Income (Income before taxes & deductions for health insurance, etc.)

No incomeLess than $1,000/month (Less than $230/week)$1,000 to $2,000/month ($230 to $461/week)$2,001 to $3,000/month ($462 to $692/week)$3,001 to $4,000/month ($693 to $923/week)$4,001 to $5,000/month ($924 to $1,153/week)$5,001 to $6,000/month ($1,154 to $1,384/week)$6,001 to $7,000/month ($1,385 to $1,615/week)More than $7,000/month (More than $1,615/week)
Are you the person who needs / seeks assistance?*

YesNo. I am referring for services a family member, friend, neighbor, patient, constituent, client, etc. .No. I am neither seeking help for myself nor referring another person. I have a question that I hope OHS staff can answer.No. I am an OHS staff member.
Referrer's Name
Referrer's phone number
Referrer's email address
Referrer's relationship to person needing / seeking assistance

FriendFamily/Household memberLandlordSomerville OHSSomerville HHSSomerville COASOIA / SomerVivaSomerville Public Schools / Family Learning CollaborativeCambridge Health AllianceSomerville Police / Wellness TeamSomerville Mayor's OfficeSomerville City CouncilSomerville School CommitteeOther Provider
Should OHS follow up with you (Referrer)?

Yes. Contact me before reaching out to the person I referredYes. Please let me know whether you connect with the person I referredNo.
Survey Language
Would you like OHS to email you our quarterly newsletter containing information about resources, programs, and public policy related to affordable housing?

YesNo
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