Request Assistance Form - Windward Oahu Eviction Prevention

**2022 Windward Oahu Eviction Prevention Program**

Please fill in the following information and a member of our Community Action Teams will contact you within 2-3 business days. Please be sure to include as much contact information as possible to ensure we can reach you in a timely fashion.

Basic Contact Information

First Name*:
Last Name*:
Preferred Name:
Email:
Street Address*:
City*:
State*:
Zip Code*:
Phone:
Alternate Contact First Name:
Alternate Contact Last Name:
Alternate Contact Phone:
Alternate Contact Relationship:

Intake Questions

Are you past due and/or struggling to pay your rent?
Yes:

Are you past due and/or struggling to pay your household utility bills? Please check all that apply:
Electricity:
Water/Sewer:
Gas:

Are you or any member of your household currently unemployed?:
If yes, indicate since when (ex. January 2020):

This program is specifically helping Windward Oahu residents. Please confirm that you live between Waimanalo to Kahuku so that we can assist you through this program. If you do not live in Windward Oahu, you can visit www.oneoahu.org for more information on the City & County’s assistance programs.

I live in Windward Oahu (from Waimanalo to Kahuku)*: