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Eviction Diversion Program (EDP) Tenant Application
Tenant Information
Full Name (Head of Household)
Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Social Security Number
Gender
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Veteran
Yes
No
Disabling Condition
Yes
No
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Eviction Diversion Program (EDP) Tenant Application
Household Information
How many people live with you?
0
1
2
3
4
5
6
7
(1) Full Name
Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Social Security Number
Gender
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Veteran
Yes
No
Relationship to Head of Household
Head of Household's child
Head of Household's spouse or partner
Head of Household's other relation member (other relation to head of household)
Other: non-relation member
(2) Full Name
Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Social Security Number
Gender
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Veteran
Yes
No
Relationship to Head of Household
Head of Household's child
Head of Household's spouse or partner
Head of Household's other relation member (other relation to head of household)
Other: non-relation member
(3) Full Name
Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Social Security Number
Gender
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Veteran
Yes
No
Relationship to Head of Household
Head of Household's child
Head of Household's spouse or partner
Head of Household's other relation member (other relation to head of household)
Other: non-relation member
(4) Full Name
Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Social Security Number
Gender
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Veteran
Yes
No
Relationship to Head of Household
Head of Household's child
Head of Household's spouse or partner
Head of Household's other relation member (other relation to head of household)
Other: non-relation member
(5)Full Name
Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Social Security Number
Gender
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Veteran
Yes
No
Relationship to Head of Household
Head of Household's child
Head of Household's spouse or partner
Head of Household's other relation member (other relation to head of household)
Other: non-relation member
(6) Full Name
Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Social Security Number
Gender
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Veteran
Yes
No
Relationship to Head of Household
Head of Household's child
Head of Household's spouse or partner
Head of Household's other relation member (other relation to head of household)
Other: non-relation member
(7) Full Name
Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Social Security Number
Gender
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Veteran
Yes
No
Relationship to Head of Household
Head of Household's child
Head of Household's spouse or partner
Head of Household's other relation member (other relation to head of household)
Other: non-relation member
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Eviction Diversion Program (EDP) Tenant Application
Household Contact Information
Household (Contact Unit) Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address, if different from above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number to Reach You
-
Area Code
Phone Number
Contact Name to Leave Messages
First Name
Last Name
Contact Phone Number to Leave Messages
-
Area Code
Phone Number
Email Address
example@example.com
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Eviction Diversion Program (EDP) Tenant Application
Household Income
Does your household have any income?
Yes
No
Total monthly household income:
You will need to attach proof of the last 30 days of income at the end of this application or mail it to our office.
Please check all sources of income that your household received in the last 30 days.
Social Security Benefits
Supplemental Security Income (SSI)
Pension/Retirement Benefits
Veteran's benefits/Military Allotment
Tribal payments (Energy Assistance/LIHEAP, tribal GA, casino/gambling profit sharing, land claims, etc.)
Rental income or a land contract, mortgage or other payment payable to a household member
Disability benefits
Self-employment income
Unemployment
Child Support
Employment/earned income
Worker's Compensation
Money from Family/Friends
Other
(1) Household Member Name
First Name
Last Name
Source of Income
Rate of Pay
Payment Basis
hourly
Weekly
bi-weekly
monthly
(2) Household Member Name
First Name
Last Name
Source of Income
Rate of Pay
Payment Basis
hourly
Weekly
bi-weekly
monthly
(3) Household Member Name
First Name
Last Name
Source of Income
Rate of Pay
Payment Basis
hourly
Weekly
bi-weekly
monthly
(4) Household Member Name
First Name
Last Name
Source of Income
Rate of Pay
Payment Basis
hourly
Weekly
bi-weekly
monthly
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Eviction Diversion Program (EDP) Tenant Application
Rental Informtation
Number of Bedrooms in Unit
Move-in Date
-
Month
-
Day
Year
Date
Tenant Rent Amount
Date of Last Payment
-
Month
-
Day
Year
Date
Owner/Landlord Name
First Name
Last Name
Number of Months in Arrears
Are you past due or delinquent on your rent?
Yes
No
Amount past due or delinquent (without late fees)
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Eviction Diversion Program (EDP) Tenant Application
Tenant Signature
I certify that, to the best of my knowledge and belief, all the information presented and attached to this application is true, correct. and complete in every respect; fully discloses mv household income from all sources; and accurately represents mv/our current living circumstances.
*
Date
-
Month
-
Day
Year
Date
Checklist
Before submitting this application for the Eviction Diversion Program (EDP), please review the following to make sure that all required information is included with the application.
Please attach required documents here.
Browse Files
If you are unable to attach the required files, please e-mail them to edp-eightcap@8cap.org with the head of household's name in the subject line or mail to the address below.
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