ERAP Application Primary Application Applicant & Household InformationFinancial HardshipHousing StatusHousehold IncomePage 5Release of InformationDocumentation0% Complete1 of 7 Who is filling out this application? * I am the applicant and I am filling out the application myself. I’m filling out the application for someone else Section 1: Primary Applicant Information First Name * Middle Initial Last Name * Household Address * Household Address Address Line 1 Address Line 1 Address Line 2 Address Line 2 City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Home Phone * Cell Phone Email Confirm Email Please confirm your email address by entering it again. Preferred Language Date of Birth Gender Male Female Other Gender Race White/Caucasian Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander Hispanic or Latino? Yes No Household Size Number of Children Number of Adults Names of all adult household members, separated by commas Names of all minor household members, separated by commas Would you like to authorize an alternate contact to discuss your application? Yes No Alternate Contact Information If you would also like us to communicate directly with another person or agency on your behalf regarding your application, or if you are filling out this application for someone else, please provide the following alternate contact information: First Name Last Name Agency Name Alternate Contact Email Confirm Alternate Contact Email Please confirm the email address by entering it again. Alternate Contact Phone Persons Residing In The Household The first entry is for the Head of Household (HoH). First Name * Last Name * Gender * Male Female Other Birthdate * Race * White or Caucasian Black or African American Asian American Indian/Alaskan Native Native Hawaiian or Other Pacific Islander Multi-Racial Unknown Ethnicity * Not Hispanic or Latino Hispanic or Latino Household Member’s Age Adult Household Member’s Email Since this household member is over the age of 18, they will need to sign a ‘Release of Information’ form. To invite them to sign this form online (fastest), enter their email address here. You may also download and print a paper copy of the form here. Confirm Adult Household Member’s Email Please confirm the email address by entering it again. Add Remove If you are human, leave this field blank. Next
