CEPP - Landlord Statement

LANDLORD STATEMENT

Housing Stability Services
211 SE Byers Ave
Pendleton, OR 97801
541-276-1926 | 800-752-1139

Serving Gilliam, Hood River, Morrow, Sherman, Umatilla, Wasco, and Wheeler counties
All fields marked with an asterisk (*) are required

To be completed by Owner or Authorized Agent
Date*

MonthDayYear
Tenant Name(s)*
Tenant Address*

Street Address

Street Address Line 2

CityState

ZIP Code

Have you or will you be applying for landlord assistance for this tenant for any past or present rent due?*

YesNo

Upon completion and approval, CAPECO will authorize a one-time payment towards the rent. Funds paid by CAPECO are to prevent eviction for nonpayment of rent.

By signing this form, you are certifying the amounts you have detailed below and agree you will not evict based on nonpayment of rent for the periods covered in the payment amount.
ADDITIONAL SENTENCES WERE USED IN PREVIOUS LANDLORD STATMENT FORMS:

Upon completion and approval, CAPECO will authorize a one-time payment towards the rent. Funds paid by CAPECO are to prevent eviction for nonpayment of rent. Funds may reflect past, present and future rent. If tenant leaves the unit with credit of rent not utilized, rent must be returned to the tenant.

By signing this form, you are certifying the amounts you have detailed below and agree you will not evict based on nonpayment of rent for the periods covered in the payment amount.
Monthly Rent amount*
$ / month
Amount past due*
$
Late fee*
$
TOTAL Amount Due*
$
Rent past due date*

MonthDayYear
Date
Rent Past Due
$

Make Checks Payable to:
Business or Owner's Name*
Mailing Address*

Street Address

Street Address Line 2

CityState

ZIP Code
Phone Number*

Area CodePhone Number
Business type*

Individual / Sole Proprietorship or Single-Member LLCC CorporationS CorporationPartnershipTrust / EstateLLC

Please upload the following documents:
- IRS form W-9 page1
  - Blank IRS form W-9
- Tenant Ledger
  - If your system does not have a tenant ledger, please fill out our Tenant Ledger form
Upload IRS form W-9 page 1 and Tenant Ledger here*

Browse Files
File types accepted: pdf, jpg, jpeg, png, gif Cancelof
Owner or Authorized Agent*

First NameLast Name
Signature of Owner / Authorized Agent*

Clear
Date

MonthDayYear
Date
Working Email
A copy of this completed form will be emailed to this address

.
In order for CAPECO to complete the eligibility determination for {typeA}'s application we will need Federal Tax ID Number or Social Security Number (SSN) for your business. You may provide the numbers here or you can complete a paper form and mail it to us with the requested information.
- To provide a Federal Tax ID or SSN here, read the entire terms and conditions and select the first box.
- To mail a paper form that includes your Federal Tax ID or SSN read the entire terms and conditions and select the second box, then print out a form, complete it and mail it to CAPECO, ATTN Housing/COVID19, 721 SE 3rd St STE D, Pendleton OR 97801 or fax to 541-276-7541.
Sign here to agree to provide the Owner's Federal Tax ID Number or Social Security Number here.

Clear
Owner's Social Security # or Federal Tax ID #
Provide an email address below if you would like a 'Landlord Statement' emailed to you.

We will also provide a link to the form after you click 'Submit' below.
Print Owner or Authorized Agent Name
Signature of Owner or Authorized Agent

Clear
Date

MonthDayYear
Tenant(s) Name
Should be Empty:

LANDLORD STATEMENT