The Colony COVID-19 Relief Fund

Do you live in The Colony, TX?*
- Yes
- No
Assistance is currently ONLY available to The Colony, TX residents.

For additional resources in Denton County please go to United Way Denton - COVID-19 Resources.
Have you applied for assistance from any agency in Denton County (including Next Steps) or the State of Texas Rent Relief Program in 2021?
- Yes
- No
Client Information
Next Steps believes in equal rights for all and does not discriminate on the basis of race, color, religion, national origin, sex, disability, sexual orientation, or gender identity.
Have you lost your job, hours or income because of COVID-19
- Yes
- No
If yes, please attach a screenshot of a letter, email, or text from your employer
Name*
First Middle Last Suffix
SSN*
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
- Female
- Male
Are you pregnant?
- Yes
- No
The Colony Street Address*
**NOTE: ONLY AVAILABLE FOR RESIDENTS OF THE COLONY, TX**

Street Address City State ZIP Code
Please note that due to fund restrictions this is only available to residents of The Colony, TX 75056.
Please list the ages of everyone in the household
Phone Number*
Email*
I identify my race as:*
Hispanic/Latino*
- Yes
- No
Veteran
Are you a veteran?*
- Yes
- No
Domestic Violence
Are you a domestic violence victim/survivor?*
- Yes
- No
If yes, when did the experience occur?
If yes, are you currently fleeing?
- Yes
- No
Disabling Condition
Do you have a disabling condition?*
- Yes
- No
If yes, please explain your condition
If yes, is the disability expected to be of long-continued and indefinite duration and substantially impair your ability to live independently?
- Yes
- No
Developmental Disability
Do you have a developmental disability?*
- Yes
- No
If yes, is the disability expected to substantially impair your ability to live independently?
- Yes
- No
Chronic Health Condition
Do you have a chronic health condition?
- Yes
- No
If yes, is the chronic health condition expected to be of long-continued and indefinite duration and substantially impair your ability to live independently?
- Yes
- No
HIV/Aids
HIV/Aids*
- Yes
- No
If yes, is the disability expected to substantially impair your ability to live independently?
- Yes
- No
Mental Health
Mental health problem*
- Yes
- No
If yes, is the chronic health condition expected to be of long-continued and indefinite duration and substantially impair your ability to live independently?
- Yes
- No
Substance Abuse
Substance abuse problem*
- Alcohol abuse
- Drug abuse
- Alcohol and drug abuse
- None
For alcohol abuse, drug abuse, or both alcohol and drug abuse is the substance abuse problem expected to be of long-continued and indefinite duration and substantially impair your ability to live independently?
- Yes
- No
Income
Have you applied for unemployment?
- Yes
- No
Do you receive income from the following source(s)*
- Earned income
- Unemployment insurance
- Supplemental Security Income (SSI)
- Social Security Disability Income (SSDI)
- VA Service-Connected Disability Compensation
- VA Non-Service-Connected Disability Pension
- Private Disability Insurance
- Workers Compensation
- Temporary Assistance for Needy Assistance (TANF)
- General Assistance (GA)
- Retirement Income from Social Security
- Pension or retirement income from a former job
- Child support
- Alimony or other spousal support
- Other
- None
Earned Income: List amount*
Unemployment insurance: List amount*
Supplemental Security Income (SSI): List amount*
Social Security Disability Income (SSDI): List amount*
VA Service-Connected Disability Compensation: List amount*
VA Non-Service-Connected Disability Pension: List amount*
Private Disability Insurance: List amount*
Workers Compensation: List amount*
Temporary Assistance for Needy Assistance (TANF): List amount*
General Assistance (GA): List amount*
Retirement Income from Social Security: List amount*
Pension or retirement income from a former job: List amount*
Child support: List amount*
Alimony or other spousal support: List amount*
Other: List type and amount*
Non-cash Benefits
Do you have any non-cash benefits from the following source(s)*
- Supplemental Nutrition Assistance Program (SNAP)
- Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
- TANF Childcare Services
- Other
- None
Supplemental Nutrition Assistance Program (SNAP): Monthly amount*
Special Supplemental Nutrition Program For Women, Infants, and Children (WIC): Monthly amount*
TANF Childcare Services: Monthly amount*
Other: List source and monthly amount*
Health Insurance
Are you currently covered by health insurance?*
- Yes
- No
If yes, choose from the following list
- Medicaid
- Medicare
- State Children's Health Insurance
- VA Medical Services
- Employer-provided health insurance
- Health insurance obtained through COBRA
- Private pay health insurance
- State health insurance for adults
- Indian health services program
- Other
If other, please specify
Next Steps
How did you hear about Next Steps?
Have you been helped by Next Steps in the past?
- Yes
- No
When?
Date Format: MM slash DD slash YYYY
Explain your situation
I need emergency assistance from Next Steps with...*
Approximate financial need*
Enter a dollar ($) amount. If no financial assistance is needed, please enter a 0.
If asking for housing assistance, how many months are you behind?
If behind, which months are you behind?
- March 2020
- April 2020
- May 2020
- June 2020
- July 2020
- August 2020
- September 2020
- October 2020
- November 2020
- December 2020
- January 2021
- February 2021
- March 2021
- April 2021
- May 2021
- June 2021
- July 2021
- August 2021
- September 2021
- October 2021
- November 2021
- December 2021
If asking for housing assistance, do you owe late fees and how much?
If asking for housing assistance, please attach a copy of the front page of your lease
Please attach a copy of your rent LEDGER. This can be obtained from your landlord. The ledger should start with the last month where you were completely caught up on rent.
Landlord Name
Landlord Address
Landlord Phone Number
Please attach outstanding utility bills:
Gas
Electric
Water
If you live in a rental HOME (not an apartment), Please download this form (W9 Form) and have your landlord sign it, and return it to docs@nextstepstc.org. Rent checks will not be released until this has been completed.
Consent*
Filling out this form does not guarantee financial assistance from Next Steps. All requests will be reviewed by a committee and I will be contacted within 2 business days. I understand to my information will be shared with United Way in order to receive help.
I understand and agree

(972) 445-7770

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Client Information

Please note that due to fund restrictions this is only available to residents of The Colony, TX 75056.

Veteran

Domestic Violence

Disabling Condition

Developmental Disability

Chronic Health Condition

HIV/Aids

Mental Health

Substance Abuse

Income

Non-cash Benefits

Health Insurance

Next Steps

Explain your situation