EPP Application Part 2 Before starting the EPP Application, please download and fill out the following forms below. Once completed, upload them below: HMIS Fact Sheet / Consent to Collect Release for Coordination of Care Authorization Form Authorization to Use or Disclose Protected Health Information Form HMIS Fact Sheet / Consent to Collect* Release for Coordination of Care Authorization Form* Authorization to Use or Disclose Protected Health Information Form* APPLICANT INFORMATION Name* Date of Birth* Gender Choose an optionMaleFemale N/A Transgender Choose an optionMale to FemaleFemale to Male N/A Address* APT # City* State* ALABAMAALASKAAMERICAN SAMOAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFEDERATED STATES OF MICRONESIAFLORIDAGEORGIAGUAM GUHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARSHALL ISLANDSMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTANORTHERN MARIANA ISLANDSOHIOOKLAHOMAOREGONPALAUPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGIN ISLANDSVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING Zip Code* Cell Phone Number* Email* Head of Household?* YesNo Number of adults in household:* Number of children in household:* This Program is for renters who have a COVID-19 related loss or reduction of income. Please describe the COVID-19 related circumstances that led to the need for this assistance:* RACE OF APPLICANT Primary Race* American Indian/Alaskan NativeNative American/Other Pacifica IslanderAsianBlack/African American and WhiteBlack/African AmericanWhiteOther Secondary Race American Indian/Alaskan NativeNative American/Other Pacifica IslanderAsianBlack/African American and WhiteBlack/African AmericanWhiteOther Ethnicity:* Hispanic/LatinoNon-Hispanic/Non Latino U.S. Military Veteran:* YesNo Do you have a disability of long duration?* YesNo AFFECTED BY COVID-19 AND IS SEEKING ASSISTANCE Reason for Assistance* LOSS OF INCOMEREDUCTION IN HOURS Provide the following supporting documentation Letter of termination of employment reflecting termination or furlough date* Proof of filed unemployment or receiving unemployment dated as of March 2020* February AND March bank statements* W-2/1099 Tax Forms* Proof of SSI/IDA* TYPE OF ASSISTANCE Please indicate assistance type(s) and amount(s) requested Rental Assistance Utility Assistance: Rental Arrears: Utility Arrears: LANDLORD/PROPERTY MANAGEMENT Landlord or Property Management Contact Number: Payment payable to: Legal Name of Payee (Landlord/Property Owner) Address Please provide the following documentation Fully Executed Rental/Lease Agreement and Rental Addendums* Photo ID/Identification for all adult members of household* Eviction Notice of Correspondence from Landlord indication the Tenant is in arrears* UTILITY SERVICE Company Name: Address: Please provide the following documentation Utility Bills or Utility Shut Off Notice* Photo ID/Identification reflecting that member of the household is on the lease and utility account* INCOME Current household gross monthly income:* Source of Income (check all that apply): Employment SSI Social Security Retirement Veterans Benefit IDA Public Benefit Child Support Unemployment SSI SSDI MONTHLY EXPENSE Rent* Gas* Electric* Water* Food* Car payment* Insurance* Communication* Monthly Total I/We, the undersigned, agree and acknowledge that the information provided is true and correct as of the date set forth opposite my/our signature. I/We acknowledge that a material misstatement fraudulently or negligently made in this or in any other statement made by me/us may constitute a federal violation and may result in the denial of my/our participation in this program. I/We also understand that ACDS or HUD may at any time request to see documentation that can verify that the income information reported on this form is accurate and correct. Please use your mouse, stylus, or finger to sign your name in this box. Date* Submit Submit