Somerville Office of Housing Stability Referral Form

🌐 Español, Português, Kreyòl Ayisyen ↑

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.

Persons with disabilities who need auxiliary aids and services for effective communication (i.e., CART, ASL), written materials in alternative formats, or reasonable modifications in policies and procedures in order to access the programs, activities, and meetings of the City of Somerville should contact the ADA Coordinator in advance at 617-625-6600 x 2059 or ADA@somervillema.gov.

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?

Pronouns of the person seeking assistance

Other: Please type pronouns here

Current Living Situation (Select option that best describes situation)

Other

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

Is person needing assistance being evicted or pressured to leave?

Date of Most Recent Notice / Court Document

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).

Primary language(s) spoken by person needing / seeking assistance

Language Code

Is person seeking assistance able to comfortably converse in English?

Interpreter's Name (and relationship)

Interpreter's phone / email (if known)

Type of help needed / sought (select no more than 5)

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)

Race and Ethnicity of Household Member(s) (select all that apply)

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.)

Are you the person who needs / seeks assistance?

Referrer's Name

Referrer's phone number

Referrer's email address

Referrer's relationship to person needing / seeking assistance

Should OHS follow up with you (Referrer)?

Survey Language

Would you like OHS to email you our quarterly newsletter containing information about resources, programs, and public policy related to affordable housing?

Does the client know they're being referred?

How did you hear about OHS?