Eviction Prevention Application

Part 1: Household Information

Today's date

mm/dd/yyyy

Your first name

Your last name

Your physical address

Your mailing address (if different)

Your phone number

Your email address

Household's total monthly cash income amount ($)

Household's total monthly food stamp income ($)

What best describes your situation?

Household member #1 first/last name (self)

Household member #1 date of birth

mm/dd/yyyy

Household #2 member first/last name

Household member #2 date of birth

mm/dd/yyyy

Household member #3 first/last name

Household member #3 date of birth

mm/dd/yyyy

Household member #4 first/last name

Household member #4 date of birth

mm/dd/yyyy

Household member #5 first/last name

Household member #5 date of birth

mm/dd/yyyy

Household member #6 first/last name

Household member #6 date of birth

mm/dd/yyyy

Does your household currently have a HUD voucher?

If no, has your household applied for a voucher?

Has a household member served in the military?

Is any member of the household a farmworker?

Has the household received an eviction notice?

Eviction court case number (if you have one)

Is at least one household member under age 18?

Any serious medical conditions in the household?

If you selected yes, explain medical condition(s):

Is any household member fleeing domestic violence?

Were you referred to us by another organization?

If you selected yes, write name of organization

Name of person at organization who referred you (if applicable)

Email address of person at organization who referred you (if applicable)

Phone number of person at organization who referred you (if applicable)

Does anyone in the household have a disabling condition?

If yes, please explain

Documentation

In order to complete this request for assistance, you need to provide us with copies of documentation that help us verify your identity, need for assistance, and other details related to your application.

If you choose to upload digital copies of the documents listed below, please make sure the documents are legible and clear. Please make sure no portion of your documents get cut off if you use your phone's camera or a scanner to capture and upload images of them.

If you are not able to upload digital copies of the documents listed below, please come to one of our offices to drop off your documentation or have our staff make copies for your file. Please note that your request for assistance will not be considered complete until we have copies of your required documents, even if you submit the remainder of your request online today.

Our office in The Dalles is located at 312 E. 4th St. and our office in Hood River is located at 606 State St., Suite 1B. Our offices are open 8am-12pm and 1pm-5pm Mondays through Thursdays.

Which documents are you uploading today? (check all that apply)

File Upload

Drop your files here

Part 2: Housing Status

Select the option that best describes your housing situation

You can read more here about each option listed below.

Do you have a caseworker or other individual who can verify your housing status?

If yes, what is their first and last name?

If yes, what is their email address?

If yes, what is their phone number?

Part 3: Landlord Information

In order to verify information about your rent assistance request, and to make payment if your request is approved, we need to contact your landlord. By completing the information below, you are consenting to give MCCAC staff permission to contact your landlord about the details of your rent assistance application.

What is your landlord's first and last name?

What is your landlord's phone number?

What is your landlord's email address?

Part 4: Rent Assistance Request

What is the total amount (in dollars) of overdue rent assistance you are requesting?

Note: our program allows for no more than 6 months of overdue rent to be paid.

What is the total amount (in dollars) of future rent assistance you are requesting?

Note: If you do not have an eviction notice, you are not eligible to apply for future rent assistance. If you DO have an eviction notice, you can apply for up to three months' of future rent assistance, or the least amount of rent assistance needed to avoid eviction, whichever amount is less.

What month(s) is this rent assistance for?

Have you requested assistance for this same rent from any other programs?

If yes, please write the name of the other program

If you have an active eviction notice or court case, are you interested in learning more about free legal or mediation assistance that may help you?

If you select "yes," you give permission to MCCAC staff to help you get free support from a lawyer with the statewide Oregon Eviction Defense Project, or to help you find free, local legal assistance from a lawyer of your choice. You also agree to let MCCAC staff share your information with Six Rivers Dispute Resolution Center, which provides free mediation assistance. Once MCCAC staff has connected you to these free resources, it is up to you to decide if you want to use them.

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