EEPPN Application "*" indicates required fields 1Client Information2Household Demographic3Rental Information4Household Income5Attestation Statement6Income Attestation7Release of Information and Liability This field is hidden when viewing the formCase StatusThis field is hidden when viewing the formAdvisor / IntakeReferral Source*Name (First, Last)** As shown on your Birth Certificate or State ID* Preferred Name *If Applicable*Date of Birth* MM slash DD slash YYYY Age*Last 4 of SS#*Phone*Email* Address* Street Address Unit City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you a past client of EEPPN?* Yes No Past Case Number*Are you negligent on your rent?* Yes No Balance Owed*Are you currently under eviction?* Yes No If so, what kind?*3-Day7-Day pay or Quit30-Day No Cause30-Day Pay or QuitOtherIf other, please specify.*Notice Date* MM slash DD slash YYYY Do you have an eviction hearing set up with the court?*YesNoCourt Date MM slash DD slash YYYY Have you been served a 24-hour lockout order or similar notice?* Yes No If yes, when?* MM slash DD slash YYYY Please upload your lockout notice.*You may upload more than one document if needed. Drop files here or Select files Max. file size: 100 MB. Are you currently homeless?* Yes No If yes, how long?*Are you currently employed?* Yes No What led to you being homeless?*What services are you requesting?* Eviction Prevention Crisis Relocation Sustainability Advisory COVID-19Have you or anyone in the home been diagnosed with Covid-19?* Yes No Who?*When?* MM slash DD slash YYYY Please upload proof, such as a positive COVID-19 test (not mandatory).You may upload more than one document if needed. Drop files here or Select files Max. file size: 100 MB. Have you or anyone in the home had a financial loss due directly or indirectly to Covid-19?* Yes No Please explain.* Number of household members*Please enter a number greater than or equal to 1.# of adults in HH0123456More than 6# of children in HH0123456More than 6# of seniors in HH0123456More than 6# of veterans in HH0123456More than 6# of students in HH0123456More than 6Please provide details on the first resident.*NameDate of BirthSocial Security #GenderRelationshipDisabled?Senior?U.S. Veteran?Student?Felon? Add RemoveIf you do not enter information on each resident, it could delay the progress of your case.Please provide details on the second resident.*NameDate of BirthSocial Security #GenderRelationshipDisabled?Senior?U.S. Veteran?Student?Felon? Add RemoveIf you do not enter information on each resident, it could delay the progress of your case.Please provide details on the third resident.*NameDate of BirthSocial Security #GenderRelationshipDisabled?Senior?U.S. Veteran?Student?Felon? Add RemoveIf you do not enter information on each resident, it could delay the progress of your case.Please provide details on the fourth resident.*NameDate of BirthSocial Security #GenderRelationshipDisabled?Senior?U.S. Veteran?Student?Felon? Add RemoveIf you do not enter information on each resident, it could delay the progress of your case.Please provide details on the fifth resident.*NameDate of BirthSocial Security #GenderRelationshipDisabled?Senior?U.S. Veteran?Student?Felon? Add RemoveIf you do not enter information on each resident, it could delay the progress of your case.Please provide details on the sixth resident.*NameDate of BirthSocial Security #GenderRelationshipDisabled?Senior?U.S. Veteran?Student?Felon? Add RemoveIf you do not enter information on each resident, it could delay the progress of your case.Please provide details on the seventh resident.*NameDate of BirthSocial Security #GenderRelationshipDisabled?Senior?U.S. Veteran?Student?Felon? Add RemoveIf you do not enter information on each resident, it could delay the progress of your case.Upload Documentation*We will need birth certificates, social security cards, driver's licenses of all residents. You may upload more than one document. Drop files here or Select files Max. file size: 100 MB. Preferred Language* Property Name*Property Manager Name*Landlord Phone*Landlord Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Dwelling* House Apartment Mobile Home Motel Other Do you have a lease?* Yes No When does it expire?* MM slash DD slash YYYY Are you month-to-month?* Yes No Do you reside on a lease anywhere else?* Yes No If yes, please explain.*Do you sublet?* Yes No If yes, please explain.*What is your current rent amount?*How many bedrooms are in your unit?*Are utilities included?* Yes No Have you or any adult in the home had any evictions in the past 7 years?* Yes No If yes, who?*What City/State?*Have you or any adult in the home applied anywhere in Washoe County for rental assistance within the last 48 months?* Yes No If yes, who?*What agency?*What was the result? Approved Denied Amount*Have you or any adult in the home ever applied anywhere in Washoe County for deposit assistance in the past?* Yes No What agency?*What was the result? Approved Denied Amount*Does anyone or any agency pay all or part of your living expenses?* Yes No If yes, who?*How much?*How often?* Upload Paystub or Proof of Income* Drop files here or Select files Max. file size: 100 MB. Upload all pays stubs or proof of income for ALL household members for the last 90 days or above each income upload inside each household member section state upload pay.What is the Gross Monthly Income for your household?*How much cash do you have on hand at this moment?*Income Source*EmploymentSocial SecuritySSISSDAlimonyChild SupportTANFLoansOtherIf other, what kind?*Amount*EmployerTitlePhoneEmployer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY On furlough? Yes No If yes, when?* MM slash DD slash YYYY Do you anticipate a new source of income starting within the next 30 days?* Yes No Did you or anyone in the home file for DETR unemployment benefits?* Yes No Upload ProofYou may upload more than one document if needed. Drop files here or Select files Max. file size: 100 MB. Who?*Result* Approved Denied Weekly benefit amount*Are you on TANF?* Yes No Upload ProofYou may upload more than one document if needed. Drop files here or Select files Max. file size: 100 MB. Amount receiving*How often?*Are you on Food Stamps?* Yes No Amount receiving*How often?*Upload OrderYou may upload more than one document if needed. Drop files here or Select files Max. file size: 100 MB. Do you have health insurance?* Yes No What provider?*Have you or anyone (above the age of 18) in the home been unemployed for 90 days or more?* Yes No Do you have any assets to declare? Yes No Please check Yes or No if you have any assets you have to declare. (I.E Bank accounts, Investment Properties, Stocks, ETC...) DeclarationBy checking this box, you verify that you DO NOT have any income.* Yes, I verify that I have no income. When was the last time you had income?* MM slash DD slash YYYY What was the income source?*What led to the loss of income?*What is prohibiting you from obtaining income currently?*Name*I declare under perjury of law int eh State of Nevada that the foregoing is true and correct.Today's Date* MM slash DD slash YYYY By checking the box below, you declare under penalty of perjury that the following statement is true and correct.* Yes, the following statement is true and correct.As you are unable to validate a situation or income loss by document, we ask that you provide a statement of what occurrence that resulted in your need for emergency housing assistance.*Signature*Date* MM slash DD slash YYYY Head of Household Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country View the Latest HUD CalculationsBy checking the box below, you declare under penalty of perjury that the following statement is true and correct.* Yes, the following statement is true and correct.Household IncomeThis selection describes my current yearly household income from ALL sources.* Based on the number of members in my household, our total current household income is at or BELOW 80% of the Area Median Income (AMI) according to HUD's calculations. Based on the number of members in my household, our total current household income is ABOVE 80% of the Area Median Income (AMI) according to HUD's calculations. PrioritizationThe checked box(es) describes my situation.* Based on the number of members in my household, our total current household income is at or below 50% of the Area Median Income (AMI) according to HUD's calculation. A member of my household has been unemployed for at least the last 90 days. Signature of applicant certifies that all information is true and correct. I understand that this information is to be used to determine eligibility for program assistance. I understand that the falsification or omission of any information on my application, any program paperwork or any other documents may cause denial and/or termination of any program services offered by the program, prosecution for a category D felony pursuant to NRS 199.145, and I may have to repay the benefits received.Name* First Last Client Signature*Date* MM slash DD slash YYYY DeclarationRisk of Homelessness of Housing Instability*Check all that apply Without rental assistance, I am at risk of being evicted. I have been issued an eviction notice due to unpaid rent. I have a past due notice for my rent or utilities. My current living situation is unsafe or unhealthy. I am currently unhoused. I need guidance on how to become sustainable. Initials*By initialing, I confirm that I am unable to provide proof of sustainable income and declare under penalty of perjury that all statements I have made on this questionnaire (application for services) are true and correct.Any other documents you'd like to share? (Optional)Max. file size: 100 MB.Signature*I swear under penalty of perjury of law that the information in this application is true and accurate to the best of my knowledge and any falsifying of information to receive benefits is a felony US Code 1324c. If this client does NOT contact back within 15 days, this case is subject to close with no notice to client. Date* MM slash DD slash YYYY Release of Information and Liability* I agree to the below statement.I consent to the release of information I have provided to The Emergency Eviction Prevention Program of Nevada (EEPPN) as well as all agents, affiliates, employees, or representatives whereas to use for the purposes of obtaining resource possibilities to assist in the goal of rental assistance and/or other assistance that will intercept the systemic or possible systemic breakdown resulting in homelessness or to obtain assistance to eliminate homelessness. I authorize EEPPN as well as all agents, contractors, affiliates, employees, or representatives to have correspondence and/or obtain documentation from landlord, employer, agency, or any other entity that is a reasonable party to gather character and/or business doings for the purposes of obtaining history that can and will be used in the decision making of possible benefit approval or services rendered. I swear to it that the information I have provided is true and accurate to the best of my knowledge and understand that if I am untruthful to falsely obtain benefits or services, I can be denied resources, that I am liable to completely reimburse the agency that supplied funding and can be held criminally liable for falsifying information to obtain benefits or services. I agree that my information may be used or transferred to other agencies such as government entities, nonprofit organizations, city funded programs, and/or any other agency or individual that EEPPN sees fit to share information with for the purpose of obtaining resources on behalf of the client or decision making of benefits/services. I authorize EEPPN to sign, attest, or swear in on my behalf as my agent or advisor to agencies and affiliates with the intention of obtaining benefits or information. This program, or any of its affiliates, holds no promise of any benefits to any individual at any time. If the advisor feels that they choose to end services for any reason or none, that is the right and will henceforth be known as “elective quit”. Program directors, advisors, staff members, independent contractors, subcontractors, or any agent approved to deliver advisory hold no licensing in the real estate, legal, or medical field, they do not possess any mental health degrees therefore any advisory given, or data collected is strictly for formulation purposes. Options and directives are from a consulting and advisory position and are at the discretion of the receiver to accept and follow or deny. I understand that by applying I am not promised anything except formulation of data and directional consultation. I agree to not hold EEPPN, agents, clients, contractors, affiliates, employees, and/or representatives responsible for any consequence that may arise due to EEPPN involvement in my situation. I understand I am at risk and that any decision made is purely made under my own discretion.Signature*I understand by signing this document I am agreeing to the terms stated above as a representative of the household.Print NameDate* MM slash DD slash YYYY Release of InformationMax. file size: 100 MB.Please use the link below to download a copy of the Release of Information. This document has to be signed in pen. Have all other adults in the household complete and upload as a PDF. (Anyone 18 and over is required to sign)Medical Release of Information* I agree to the following release of informationI consent to release necessary medical information to the Emergency Eviction Prevention Program of Nevada (EEPPN) and to all of its affiliates as needed in order to locate resources with the goal of obtaining, retaining, or sustaining permeant housing. View the release of informationThis field is hidden when viewing the formServices Provided Eviction Prevention Crisis Relocation Sustainability Advisory Resource Navigation Failed To Complete / Contact This field is hidden when viewing the formHousehold AMI No Income 30% 50% 60% 80% Above 80% EmailThis field is for validation purposes and should be left unchanged.
