Eviction Prevention
Prescreening Application

Family must include a minor child (under the age of 18 years old)

Family must have a valid lease in their name and children’s name

Family must have an eviction letter or final notice/shut off letter in their name

Family must have a valid form of ID (State issued/Driver’s License, Passport, Work Visa)

Family must have verification of full-time employment income

Family must be able to sustain housing (<85% debt to income ratio)

Family must be able to contribute a minimum of 25% towards the need

If you meet the above qualifications, you MUST also agree to the prevention guidelines:

Family must be willing to engage in case management services based on recommendation of Outreach Manager

Family must complete case management to be eligible for more financial support within a calendar year through partner agencies

Applications will be reviewed in the order they are received. If you meet the qualifications of the program, an FP outreach case manager will be in touch. A return phone call does not guarantee funding. *

Today's Date*

MM

DD

YYYY

Birthday of Primary Adult: *

MM

DD

YYYY

Birthday of Secondary Adult: *

MM

DD

YYYY

Phone Number:* *

Country

(###)

###

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Type of Verifiable Income * *

Work Income

Disability

SSI

Other

Complex/Landlord phone number:

Country

(###)

###

####

Do you have an Eviction Court Date: * *

Yes

No

When is your Eviction Court Date (if applicable):

MM

DD

YYYY

Have you previously received funds from any organization to prevent eviction? *

Yes

No

If yes, when did you receive assistance?

MM

DD

YYYY