ERAP Application Form

First name

Last name

Birthday

Month

Day

Year

Phone

Number of People in Household (required)

Housing Information

Multi-line address

Country/Region

Address

City

Zip / Postal code

Rent or Mortgage?

Total Amount Past Due

Please provide - Landlord / Property Manager Name, Landlord Phone Number Landlord Email Address

Have you received an eviction notice?

Yes – court date

Yes – notice only

Court Date

Financial Information

Total Monthly Household Income

Primary Source of Income

Type of Financial Hardship

Type of Assistance Needed

Are you currently receiving other rental assistance?

Describe your situation

How did you hear about us?

"I certify that all information provided is true, accurate, and complete. I understand that this application does not guarantee assistance, that funds are limited and distributed on a first-come, first-served basis, and that my place in line will determine response time. I agree to notify Evergreen Community Capital of any changes to my housing or financial situation while my application is under review."