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2. First Name*
3. Last Name*
5. Address*
6. City
7. State
9. Zip Code*
11. Phone Number*
13. Email Address*
15. How many rental units do you own in Wellington?*
17. Please list the addresses of your Wellington rental units:*
19. How many units are currently vacant?*
21. How many of your tenants are struggling to pay rent?*
23. What is the cost of monthly rent at your unit(s)?

    1. $0-$1,300
    2. $1,301-$1,700
    3. $1,701-$2,100
    4. $2,101-$2,400
    5. +$2,401
25. How many months have the tenants been struggling to pay the rent?*

    1. O-2 Months
    2. 3-5 Months
    3. 6-8 Months
    4. 9+ Months
27. Which kind of assistance do your tenants need?*

    1. Partial Assistance
    2. Full Assistance
    3. N/A
29. Do you have any intentions on issuing evictions once the state moratorium is lifted?*

    1. YES
    2. NO
31. Have any of your tenants participated in the Palm Beach County Rental Assistance Program?*

    1. YES
    2. NO
33. What is the average tenant household size?*
35. Any additional comments
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37. 1. Receive an email copy of this form.
38. Email address

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39. Submit

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