CEPP - Application

CAPECO Eviction Prevention Program

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

Serving Gilliam, Hood River, Morrow, Sherman, Umatilla, Wasco, and Wheeler counties
Applicant’s will need the following documentation to be considered eligible for CAPECO Eviction Prevention Program (CEPP):
- Completed CEPP Application
- Proof of ID for all adult members of the household
- Proof of income for the prior 30 days for all adult household members
- Proof of rental obligation or rental contract
- Eviction notices or related eviction documentation (such as a 10-day notice to pay or vacate, 72-hour notice to pay)
- Landlord Statement**
Applications are processed on a priority basis.

**Please note that the Landlord Statement can be automatically emailed to your landlord or property manager during the online application process.
Select your county of residence*

GilliamMorrowUmatillaWheelerOther

This application is for Oregon residents living in Gilliam, Morrow, Umatilla or Wheeler counties only. If you live outside these counties please contact an agency in your county of residnece - See the Directory of Oregon Community Action Agencies below.

Baker County - Community Connection of NE Oregon - ccno.org, 541-963-3186
Benton County - Community Services Consortium - communityservices.us, 541-928-6335
Clackamas County - Clackamas County Social Services - clackamas.us/h3s, 503-650-5697
Clatsop County - Community Action Team Inc - cat-team.org, 503-397-3511
Columbia County - Community Action Team Inc - cat-team.org, 503-397-3511
Coos County - Oregon Coast Community Action - orcca.us, 541-435-7080
Crook County - Neighbor Impact - neighborimpact.org, 541-548-2380
Curry County - Oregon Coast Community Action - orcca.us, 541-435-7080
Deschutes County - Neighbor Impact - neighborimpact.org, 541-548-2380
Douglas County - United Community Action Network - ucancap.org, 541-956-4050
Grant County - Community Connection of NE Oregon - ccno.org, 541-963-3186
Harney County - Community in Action - communityinaction.info, 541-889-9555
Hood River County - Mid-Columbia Community Action Council - mccac.com, 541-298-5131
Jackson County - ACCESS - accesshelps.org, 541-779-6691
Jefferson County - Neighbor Impact - neighborimpact.org, 541-548-2380
Josephine County - United Community Action Network - ucancap.org, 541-956-4050
Klamath County - Klamath/Lake Community Action Services - klcas.org, 541-882-3500
Lake County - Klamath/Lake Community Action Services - klcas.org, 541-882-3500
Lane County - Lane County Human Services Commission - lanecounty.org, 541-682-3798
Linn County - Community Services Consortium - communityservices.us, 541-928-6335
Lincoln County - Community Services Consortium - communityservices.us, 541-928-6335
Malheur County - Community in Action - communityinaction.info, 541-889-9555
Marion County - Mid-Willamette Valley Community Action Agency - mwvcaa.org, 503-585-6232
Multnomah County - Human Services, Youth & Family Services - multco.us, 503-988-3691
Polk County - Mid-Willamette Valley Community Action Agency -mwvcaa.org, 503-585-6232
Sherman County - Mid-Columbia Community Action Council - mccac.com, 541-298-5131
Tillamook County - Community Action Team Inc - cat-team.org, 503-397-3511
Union County - Community Connection of NE Oregon - ccno.org, 541-963-3186
Wallowa County - Community Connection of NE Oregon - ccno.org, 541-963-3186
Wasco County - Mid-Columbia Community Action Council - mccac.com, 541-298-5131
Washington County - Community Action - caowash.org, 503-693-3221
Yamhill County - Yamhill Community Action Partnership - yamhillcap.org, 503-472-0457

Today's Date*

MonthDayYear
Applicant Information
Full Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState

ZIP Code
Is your Mailing address the same as your Physical address?*

YesNo
Mailing Address*

Mailing Address

Mailing Address Line 2

CityState

ZIP Code
Do you or anyone in your household have a pending OERA rental assistance application?

YesNo
If Yes, How have you been impacted?

0/150

Have you or anyone in your household received CAPECO rental assistance any time since 2020?*

YesNo
Have you received any rental assistance from Oregon Human Development Cooperation (OHDC)?*

YesNo
If so, when?*

Landlord Name*
First and Last Name
Landlord Phone Number*

Area CodePhone Number
Landlord Address*

Street Address

Street Address Line 2

CityState

ZIP Code
Landlord Email
example@example.com
Are you related by blood, marriage, adoption, or in a relationship with the Landlord of the rental unit for which you are seeking assistance?*

YesNo
If “Yes” there may be a possibility that you will be ineligible for assistance.
A 'Landlord Statement' is required.

By entering your landlord's email above, the Landlord Statement will be automatically sent to them.

If your landlord does not have email, you will need to have them sign a physical copy of the Landlord Statement, which can be found on the CAPECO website.
Please upload a copy of your Lease or Rental Agreement here*

Browse Files
File types accepted: pdf, jpg, jpeg, png Cancelof

Please tell us who is in your household:

Additionally, in order for CAPECO to determine eligibility for this application you will need to provide Social Security Numbers (SSN) for every household member AND a state or federal issued photo identification (ID) for every household member who is 18 years old or older.

To provide SSNs and photo IDs here, read the entire terms and conditions and select the first box, then complete a row for each household member and upload copies of IDs.
Sign here to agree to provide Social Security Numbers and State or Federal issued photo identification here.*

Clear
Upload State or Federal issued photo Identification here*

Browse Files
File types accepted: pdf, jpg, jpeg, png Cancelof
List ALL household members here:

If you are not filling in all required fields for the questions on this form you will receive an error message.

To be able to move through this form you will need to fill in all required fields.

You may need to use the scroll bars to reveal all required fields above.

What is your race/ethnicity?

*Why do we ask this? HUD asks us to collect this information to make sure that laws that protect people from being discriminated against are followed. If you are uncomfortable sharing this information, please check “prefer not to answer”.
Include ALL household members listed on the previous page, check all that apply: *

Does anyone in your household have a disability?

YesNo
Does this person receive social security or veterans benefits for the disability?

YesNo
Is anyone in your household a Veteran?*

YesNo
If ‘Yes,’ please tell us who*
List the First and Last Name of each Veteran in the household

Please tell us about your household’s income:

Please list all gross income (amount before taxes/deductions) for all members of your household.

‘Sources of income’ may include wages, social security, SSI, SSDI, Veteran Benefits, TANF, child support, etc.
Who receives this income? (List all that have income. Use multiple lines if needed.)*
Upload proof of income for all adults over the age of 18 that are in the household (last 30 days)*

Browse Files
File types accepted: pdf, jpg, jpeg, png Cancelof

By signing this form, I hereby authorize CAPECO to provide information to Oregon Housing and Community Services (OHCS) including the Homeless Management Information System (Service Point). I further authorize OHCS and its agents to access any records in order to verify information given. I understand this release is good for three years from the date the application is signed.

I consent to any legally authorized investigation for confirmation of any information that I provide. I consent to have my Landlord share tenant records and other information with OHCS or its agents.

If I receive assistance to which I am not entitled as a result of withholding information or knowingly giving fraudulent information, I must repay that assistance and may be found guilty of fraud and fined up to $10,000 put in prison or both. I understand that no person may be denied assistance on the basis of race, color, sex, age, handicap, religion, national origin or political belief.

I acknowledge that I have received notice outlining my rights to request a fair hearing if my application is unjustly denied. I further understand that I must request a hearing within thirty (30) days of the completed date of the application or date of denial.
Acknowledge these Disclaimers*

ASSISTANCE LIMITS EXIST DUE TO FUNDING CONSTRAINTSAT THIS TIME, HOUSEHOLDS ARE LIMITED TO A ONE TIME APPLICATION
Signature (Adult Member)*

Clear
Date*

MonthDayYear
Signature (Additional Adult Member)

Clear
Date*

MonthDayYear
Signature (Additional Adult Member)

Clear
Date*

MonthDayYear
Signature (Additional Adult Member)

Clear
Date*

MonthDayYear

I certify that the information above and any other information I have provided in applying for housing assistance is true, accurate and complete.
Signature

Clear
Date*

MonthDayYear
Co-Applicant Signature

Clear
Date*

MonthDayYear

Hearing Rights:

If you disagree with the denial or limits of eligibility or of the termination or modification of benefits or other assistance awarded by CAPECO, you can request an informal review within thirty (30) days of the decision, by contacting CAPECO. A request for an informal review shall be personally presented, either orally or in writing so the grievance may be discussed informally and settled without a hearing.

If you cannot settle the issue this way or you are still not satisfied you may request a hearing, in writing, to occur within thirty (30) days after the informal review. The Complainant will be provided with a copy of CAPECO’s Formal Hearing Process. A Hearing Officer will arrange a date, time and place convenient to both you and CAPECO. After your request is received, a fair hearing will be scheduled within fourteen (14) days. In preparing for the hearing you have the right to examine any documents, including records and regulations that are directly relevant to the hearing. You have the right to be represented by counsel or other person chosen as your representative. You have the right to a private hearing unless you request a public hearing. You have the right to present evidence and arguments in support of your grievance and to controvert evidence. You also have the right to cross-examine all witnesses. The Hearings Officer must render a decision within ten (10) days of the hearing. The decision of the Hearings Officer will be final.

Personally Identifiable Information:

Personally identifiable information is protected by federal laws (Privacy Act of 1974, as amended) and will be collected for the purpose of determining program eligibility, providing assistance/service, data collection, reporting and monitoring. Personally identifiable information will be shared with Oregon Housing and Community Services and other state agencies with an information sharing agreement with OHCS and are administering programs that serve the same or similar clients or populations, as is necessary to carry out the intent of an assistance or service program for the benefit of the person applying for such assistance or service and will be disclosed to Oregon Housing and Community Services without written authorization.

When a case manager reaches out to you, you will have 48 business hours to return any documentation that is missing from your application. If you do not return your documents in the allotted time frame you will be denied, at that time you will need to reapply if you continue to need assistance.

Applications are processed by priority.

OFFICE USE ONLY - DO NOT WRITE IN SHADED AREA

Completed Application Received – Date Stamp / Time: ____________

⬜ Staff Member ____________________

⬜ Total amount approved $________________

⬜ Date of Approval __________________

⬜ Reviewed by __________________

⬜ Date submitted to Finance _________

Check Number _________

Date Paid _________

Should be Empty:

CAPECO Eviction Prevention Program

Applicant Information