Eviction Prevention Assistance Application 2024

1

Application Assistance:

Eviction Prevention Project

This information will be made available in alternative format upon request.

Research Disclaimer

Please note that your application will be shared with our evaluator, Wilder Research. The reason we share this information is to learn more about the people who receive Direct Housing Assistance. Wilder Research will combine data (such as your family's income and rent amount) across all applications; you will not be singled out in any manner and your individual data will not be shared in our report.

Application Instructions

Any applicant who purposefully falsifies misrepresents or withholds any information related to program eligibility or submits inaccurate and/or incomplete information on this application or during the intake process may be rejected for financial assistance consideration.
2
Are you requesting a language interpreter?
Yes
No
3
What is your main language?* This field is required.
4
How do you use your main language?* This field is required.
Spoken
Written
5
Applicant Contact Information* This field is required.List Head of Household (H.O.H) and all applicants 18 years and older.
Full Name (Last Name, First Name, M.I.)
D.O.B. (Month/Day/Year)
Social Security Number
Contact Phone Number
Email Address
H.O.H
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Co-Applicant
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Co-Applicant
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
H.O.H
Co-Applicant
Co-Applicant
Full Name (Last Name, First Name, M.I.)
Row 0, Column 0
D.O.B. (Month/Day/Year)
Row 0, Column 1
Social Security Number
Row 0, Column 2
Contact Phone Number
Row 0, Column 3
Email Address
Row 0, Column 4
Full Name (Last Name, First Name, M.I.)
Row 1, Column 0
D.O.B. (Month/Day/Year)
Row 1, Column 1
Social Security Number
Row 1, Column 2
Contact Phone Number
Row 1, Column 3
Email Address
Row 1, Column 4
Full Name (Last Name, First Name, M.I.)
Row 2, Column 0
D.O.B. (Month/Day/Year)
Row 2, Column 1
Social Security Number
Row 2, Column 2
Contact Phone Number
Row 2, Column 3
Email Address
Row 2, Column 4
1 of 3
6
Current Address* This field is required.Street Number, Street Name, City, Zip
7
Move-In Date* This field is required.
Date
Month
Day
Year
8
Move-Out Date (if applicable)
Date
Year
Month
Day
9
Landlord Name* This field is required.
10
Landlord Address (Street Number, Street Name, City, Zip)* This field is required.
11
Phone Number* This field is required.
12
Landlord Email* This field is required.Landlord email information required for application to be reviewed.
13
Monthly Rent Amount* This field is required.
14
Date of Last Rent Payment and Amount* This field is required.
15
Current Balance Owed for Rent* This field is required.
16
For which monthly expenses are you requesting assistance?* This field is required.Select all that apply.
Past Due Rent* You are required to upload a copy of your rent ledger.
Past Due Mortgage * You are required to upload a copy of past due statement.
Are You Facing Eviction? *You are required to upload a copy of your eviction notice.
Other
17
Does anyone in the household, including yourself, have a source of income?* This field is required.
Yes
No
18
Please explain how you plan to resume paying rent after receiving eviction project funds.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
19
Have you ever received rental assistance from any Amherst H. Wilder Foundation program in the past twelve (12) months?* This field is required.
Yes
No
20
Please list the program name that has provided you with assistance.* This field is required.
21
Have you ever received rental assistance from any human service agency in the past twelve (12) months?* This field is required.Examples include the Salvation Army, Emergency Assistance, Neighborhood House, etc.
Yes
No
22
Please list the program name that has provided you with assistance, and the amount.* This field is required.
23
Has your income been impacted due to recent or sudden job loss, unemployment, etc.?* This field is required.
Yes
No
24
Please provide any supporting documentation of this recent impact to your income.Examples include a layoff letter, unemployment verification, etc.
Drag and drop files here
Select files to upload
Max. file size: 14.6MB
Cancelof
25
What is your gender?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
Female
Male
Trans Male
Trans Female
Don't Know
Refuse to Answer
Non-Binary
26
What is your race?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refuse to Answer
27
Are you Hispanic?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
28
Are you a Veteran? (18+ only)Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
29
Please list all sources of income for the Head of Household. Examples include Earned Income, MFIP, GA, Social Security, SSI, Disability, Compensation, Alimony, Child Support, Pensions, Trust Funds, Annuities, Tribal Income, Income from Rental Property, and Armed Forces Reserves
Income Source
Income Source
Income Source
Income Source
Income Source
Source Type
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
$ Per Month
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
$ Per Year
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Source Type
$ Per Month
$ Per Year
Income Source
Row 0, Column 0
Income Source
Row 0, Column 1
Income Source
Row 0, Column 2
Income Source
Row 0, Column 3
Income Source
Row 0, Column 4
Income Source
Row 1, Column 0
Income Source
Row 1, Column 1
Income Source
Row 1, Column 2
Income Source
Row 1, Column 3
Income Source
Row 1, Column 4
Income Source
Row 2, Column 0
Income Source
Row 2, Column 1
Income Source
Row 2, Column 2
Income Source
Row 2, Column 3
Income Source
Row 2, Column 4
1 of 3
30
Is there anyone else living in your household?* This field is required.
YESNO
31
Household Member 1 - Enter Name (Last Name, First Name, M.I.)* This field is required.
32
Household Member 1 - What is this person's relationship with the Head of Household? (son, significant other, etc.)* This field is required.
33
Household Member 1 - Enter Date of Birth* This field is required.
Date
Month
Day
Year
34
Household Member 1 - What is their gender?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
Female
Male
Trans Male
Trans Female
Don't Know
Refuse to Answer
Other
35
Household Member 1 - What is their race?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Don't Know
Refuse to Answer
Other
36
Is Household Member 1 Hispanic?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
37
Is Household Member 1 a veteran?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
38
Please list all sources of income for Household Member 1. Examples include Earned Income, MFIP, GA, Social Security, SSI, Disability, Compensation, Alimony, Child Support, Pensions, Trust Funds, Annuities, Tribal Income, Income from Rental Property, and Armed Forces Reserves
Income Source
Income Source
Income Source
Income Source
Income Source
Source Type
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
$ Per Month
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
$ Per Year
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Source Type
$ Per Month
$ Per Year
Income Source
Row 0, Column 0
Income Source
Row 0, Column 1
Income Source
Row 0, Column 2
Income Source
Row 0, Column 3
Income Source
Row 0, Column 4
Income Source
Row 1, Column 0
Income Source
Row 1, Column 1
Income Source
Row 1, Column 2
Income Source
Row 1, Column 3
Income Source
Row 1, Column 4
Income Source
Row 2, Column 0
Income Source
Row 2, Column 1
Income Source
Row 2, Column 2
Income Source
Row 2, Column 3
Income Source
Row 2, Column 4
1 of 3
39
Is there anyone else living in your household?* This field is required.
YESNO
40
Household Member 2 - Enter Name (Last Name, First Name, M.I.)* This field is required.
41
Household Member 2 - What is this person's relationship with the Head of Household? (son, significant other, etc.)* This field is required.
42
Household Member 2 - Enter Date of Birth* This field is required.
Date
Month
Day
Year
43
Household Member 2 - What is their gender?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
Female
Male
Trans Male
Trans Female
Don't Know
Refuse to Answer
Other
44
Household Member 2 - What is their race?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refuse to Answer
45
Is Household Member 2 Hispanic?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
46
Is Household Member 2 a veteran?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
47
Please list all sources of income for Household Member 2.Examples include Earned Income, MFIP, GA, Social Security, SSI, Disability, Compensation, Alimony, Child Support, Pensions, Trust Funds, Annuities, Tribal Income, Income from Rental Property, and Armed Forces Reserves
Income Source
Income Source
Income Source
Income Source
Income Source
Source Type
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
$ Per Month
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
$ Per Year
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Source Type
$ Per Month
$ Per Year
Income Source
Row 0, Column 0
Income Source
Row 0, Column 1
Income Source
Row 0, Column 2
Income Source
Row 0, Column 3
Income Source
Row 0, Column 4
Income Source
Row 1, Column 0
Income Source
Row 1, Column 1
Income Source
Row 1, Column 2
Income Source
Row 1, Column 3
Income Source
Row 1, Column 4
Income Source
Row 2, Column 0
Income Source
Row 2, Column 1
Income Source
Row 2, Column 2
Income Source
Row 2, Column 3
Income Source
Row 2, Column 4
1 of 3
48
Is there anyone else living in your household?* This field is required.
YESNO
49
Household Member 3 - Enter Name (Last Name, First Name, M.I.)* This field is required.
50
Household Member 3 - What is this person's relationship with the Head of Household? (son, significant other, etc.)* This field is required.
51
Household Member 3 - Enter Date of Birth* This field is required.
Date
Month
Day
Year
52
Household Member 3 - What is their gender?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
Female
Male
Trans Male
Trans Female
Don't Know
Refuse to Answer
Other
53
Household Member 3 - What is their race?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refuse to Answer
54
Is Household Member 3 Hispanic?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
55
Is Household Member 3 a veteran?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
56
Please list all sources of income for Household Member 3.Examples include Earned Income, MFIP, GA, Social Security, SSI, Disability, Compensation, Alimony, Child Support, Pensions, Trust Funds, Annuities, Tribal Income, Income from Rental Property, and Armed Forces Reserves
Income Source
Income Source
Income Source
Income Source
Income Source
Service Quality
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Cleanliness
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Responsiveness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Service Quality
Cleanliness
Responsiveness
Income Source
Row 0, Column 0
Income Source
Row 0, Column 1
Income Source
Row 0, Column 2
Income Source
Row 0, Column 3
Income Source
Row 0, Column 4
Income Source
Row 1, Column 0
Income Source
Row 1, Column 1
Income Source
Row 1, Column 2
Income Source
Row 1, Column 3
Income Source
Row 1, Column 4
Income Source
Row 2, Column 0
Income Source
Row 2, Column 1
Income Source
Row 2, Column 2
Income Source
Row 2, Column 3
Income Source
Row 2, Column 4
1 of 3
57
Is there anyone else living in your household?* This field is required.
YESNO
58
Household Member 4 - Enter Name (Last Name, First Name, M.I.)* This field is required.
59
Household Member 4 - What is this person's relationship with the Head of Household? (son, significant other, etc.)* This field is required.
60
Household Member 4 - Enter Date of Birth* This field is required.
Date
Month
Day
Year
61
Household Member 4 - What is their gender?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
Female
Male
Trans Male
Trans Female
Don't Know
Refuse to Answer
Other
62
Household Member 4 - What is their race?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
Please Select
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refuse to Answer
63
Is Household Member 4 Hispanic?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
64
Is Household Member 4 a veteran?Collected for demographic purposes only. Choosing not to answer will not affect your eligibility.
YESNO
65
Please list all sources of income for Household Member 4.Examples include Earned Income, MFIP, GA, Social Security, SSI, Disability, Compensation, Alimony, Child Support, Pensions, Trust Funds, Annuities, Tribal Income, Income from Rental Property, and Armed Forces Reserves
Income Source
Income Source
Income Source
Income Source
Income Source
Source Type
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
$ Per Month
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
$ Per Year
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Source Type
$ Per Month
$ Per Year
Income Source
Row 0, Column 0
Income Source
Row 0, Column 1
Income Source
Row 0, Column 2
Income Source
Row 0, Column 3
Income Source
Row 0, Column 4
Income Source
Row 1, Column 0
Income Source
Row 1, Column 1
Income Source
Row 1, Column 2
Income Source
Row 1, Column 3
Income Source
Row 1, Column 4
Income Source
Row 2, Column 0
Income Source
Row 2, Column 1
Income Source
Row 2, Column 2
Income Source
Row 2, Column 3
Income Source
Row 2, Column 4
1 of 3
66
By signing this application, you certify that I/We understand:

the information in this application will be used to determine eligibility for housing assistance and that this information will be verified.

that any false information will make me/us ineligible for housing assistance.

that if any of this information is false, misleading or incomplete, my application may be declined or, if move-in has occurred, terminate my/our lease agreement.

I understand that if I am providing information on behalf of other people in my household, I must have consent to provide and view information about all the people that I have listed on the application and agree to safeguard their information.

I declare under the penalties of perjury that this application has been examined by me and to the best of my knowledge is a true and correct statement of every material point. I understand that a person convicted of perjury may be sentenced to imprisonment of not more than five years or payment of a fine of not more than $10,000. or both. I understand that there may be other penalties for not telling the truth.

I/We also certify that all information given in this application is true, complete and accurate.
67
Applicant Signature* This field is required.Draw your signature using your finger or mouse.
Clear
68
Date
Date
Month
Day
Year
4
1
2
3
4
5
6
7
8
9
10
11
12
Hour
14
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
69
Co Applicant Signature (if age is 18 years or older)Draw your signature using a finger or mouse.
Clear
70
Date
Date
Month
Day
Year
4
1
2
3
4
5
6
7
8
9
10
11
12
Hour
14
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
71
Co Applicant Signature (if age is 18 years or older)Draw your signature using a finger or mouse.
Clear
72
Date
Date
Month
Day
Year
4
1
2
3
4
5
6
7
8
9
10
11
12
Hour
14
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
73
Tennessen Warning: Please read the following paragraph and click "Next" to proceed.

In accordance with Minn Stat 13.04, Subd 2. You must be provided with a Tennessen Warning. The purpose of the notice is to enable you to make an informed decision about whether to give data about you your household, which could be shared with funders and others including agencies from state, federal, and local resources that help provide housing assistance, and the organization (s) identified as holding the debt for which you are seeking assistance, and others Amherst H Wilder Foundation deems necessary for information not be shared with in order to effectively manage and evaluate the program’s effectiveness. The data could also be shared upon court order or provided to the state or legislative auditor. We are required to inform you of your rights as they pertain to the private information we collect from you. The information we collect from you is classified by law as either public (anyone can see it), private (the public is not given access, but you are), or confidential (even you cannot see the information). As an applicant of this assistance, most of the information requested about you is classified as private. You are however, if you do not provide requested information, we may not be able to provide you with the services or resources you are requesting.
74
By checking this box, I acknowledge that I have read and understood the Tennessen Warning on the previous screen.* This field is required.
I acknowledge.
75
Amherst H. Wilder Foundation Non-Discrimination Notice:

The Amherst H. Wilder Foundation is committed to ensuring that all individuals have equal access to our programs, services and facilities without regard to race, color, ethnicity, language, national origin or ancestry, religion, gender, age, veteran status, political beliefs, mental or physical challenges, social economic condition or status with regard to public assistance, sexual orientation, gender identity, genetic information or medical history.
76
Survey: At Wilder, we support you AND want to connect you to the services that will support you in living the life you desire. Please select the service or services below that you are interested in receiving additional information about upon enrollment. You must click "Submit" below to complete your application!* This field is required.
Adult Mental Health & Recovery Services: provide bilingual and bicultural services outpatient therapy, addiction counseling, and community-based services.
School-Based Mental Health Programs: provide mental and behavioral health services for you that several Saint Paul schools and within District 287.
Children's & Family Mental Health Services: provide kids of all ages from birth to 17 and their families by providing children's mental health services at clinics, schools and community settings.
Wilder Center for Social Healing: offers a place for Southeast Asian adults to gather for support, fellowship, shared meals and healing.
Childcare & Preschool: provides early childhood education and care for children ages 16 months to five years.
Meals on Wheels: Affordable, nutritious meals made locally available for pickup at the Community Center for Aging or for delivery to homebound adults and seniors in Saint Paul each weekday by friendly and caring volunteers.
Customized Living Services: Daily support and care for adults living independently in Saint Paul's public housing: Hamline & Ravoux Hi-Rise.
Wilder Connect: Long term care support for those with Parkinson’s disease or memory loss and respite for caregivers.
Community Care Services: In-home support and care for adults living independently or within senior living communities.
Wellness Classes: Helping adults manage chronic conditions to improve quality of life.
Caregiver Services: Support, respite and resources for anyone actively caring for a friend, family member or neighbor.
Support Groups for Caregivers: Connect with caregivers for mutual support on your care giving journey.
Should be Empty: