Emergency Rental Assistance (ERA)

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Program Application

If you need assistance with this application, you can call 208.843.2229 from Monday through Friday, between 8am and

430 pm Pacific Time.

The Emergency Rental Assistance Program (ERAP) was created to assist households with an inability to pay rent or

utilities due to a COVID-19 related financial hardship.

The current funding source for this program will only cover eligible costs incurred prior to December 31, 2021.

Applicant eligibility requirements are:

i. Inability to pay rent/utilities due to COVID-19 related financial hardship

ii. A household member must be enrolled in a federally recognized Tribe.

iii. Must reside within the 1855 Nez Perce Treaty boundaries

iv. Have an income of 80% or less of the area median income.

This application may be completed by a renter or by a housing or service provider acting on behalf of a renter seeking

assistance. The information provided should reflect the household seeking assistance.

An eligible household that lives in a federally-subsidized residence (Section 8, Low Income Housing Tax Credit, Public

Housing, Etc.) may not receive assistance for any costs that have been or will be covered.

You will need the following documents to complete this application:

i. Financial Hardship documentation

ii. Housing Status documentation

iii. Household Income documentation

iv. Release of Information forms

(See application for further description)

Please be prepared to provide your landlord's or utility company's contact information.

If you are missing any of these documents at the time of application, program staff will follow up with you to submit

required documents.

Emergency Rental Assistance Program Application

Applicant

Middle Initial:

First Name:

Mailing Address

City

Physical Address

City

Phone/Cell number

Email Address

Race

□ American Indian/Alaskan Native

State

Zip Code

State

Zip Code

Message number

Gender: - Male

Female County:

Ethnicity

□ Hispanic or Latino

□ White

□ Black or African American

□ Asian

□ Native Hawaiian/Other Pacific Islander

□ Do Not Know

□ Do Not Wish to Answer

First Name

Last Name:

□ Non Hispanic/Non Latino

□ Do Not Know

□ Do Not Wish to Answer

Alternate Contact Information

Last Name

Phone Number

All persons residing in the household and income: Enter the Head of Household on the first line.

Other income includes but is not limited to retirement, pension, social security, disability, TANF, child support, foster

care, public assistance, alimony, etc.

First/Last Name

Date of Last 4 digits Tribal

Monthly

Other

birth

of SSN

enrollment employment

unemployment income

number

income

Housing Status: Are you at risk of experiencing homelessness due to:

Inability to pay past due rent? NoY

N # of Months past due

Total amount past due rent $

Inability to pay current/future rent? No

N Current monthly rent amount $

Inability to pay past due utilities? No

N # of Months past due

Total amount past due utilities $

Inability to pay current/future utility bills? No

N Current monthly utility bill(s) due

Currently living in a Fed. Subsidized residence?

List the federal subsidized program(s):

Are you currently receiving any federally funded rental or utility assistance?

List the rental/utility assistance program(s):

Have you applied for any other rent/utility assistance from another agency?

NoY

Please list the program/agency for which you applied:

Landlord/Property Manager Name

Mailing Address

City

Email Address

Utility company Name (1)

Mailing Address

City

Email Address

Utility company Name (2)

Mailing Address

City

Email Address

State

Zip Code

Phone Number

Account #

Zip Code

State

Phone Number

Account #

Zip Code

State

Phone Number

COVID-19 Financial Hardship

Eligibility Criteria An “eligible household” is defined as a renter household in which at least one or more individuals

meets the following criteria:

 COVID-19 Financial Hardship: Qualifies for unemployment or has experienced a reduction in household

income, incurred significant costs, or experienced a financial hardship due to COVID-19;

 Housing Status: Demonstrates a risk of experiencing homelessness or housing instability; and

 Income: Has a household income at or below 80 percent of the area median

Eligibility Criteria: (Please check all that apply)

 Unemployment

 Increased personal care costs (PPE, hygiene

products)

 Reduced Employment/Compensation

 Increased food costs

 Temporary layoff

 Increased cost for telework

 Loss of self-employment/Business Income

 Increased cost for isolation or quarantine due to

 Closure of place of employment

COVID-19

 Increased household cleaning costs

 Required to self-quarantine based on advice

 Housing costs increased, eviction, rent

 Required to quarantine based on diagnosis of

 Utility costs increased due to children being home

COVID-19

from school

 Over the age of 50 and enduring increased costs

 Experienced a large unexpected medical cost

because of the COVID-19 pandemic

related to COVID-19

 Disabled and enduring increased costs because of

 Obligation to be absent from work to care for

the COVID-19 pandemic

homebound school aged child

 Other pertinent circumstances:

 Unable to work due to experiencing financial

hardship due to no childcare

Explanation of hardship:

Required Documents:

 You will be required to provide a copy of your current lease agreement, most recent rental delinquency notice

or eviction, and/or most recent bill (if applicable).

 You will be required to provide a copy of the last two months of pay stubs for all adults, pension statement(s),

social security award letter(s), unemployment letter(s), and/or documentation of any other household income.

Copies of W2’s or tax returns for 2020 may also be accepted.

 You will be required to provide a notice or email from your employer documenting job loss, furlough, closure,

reduction in hours, or other documentation that supports your loss of income due to COVID-19. If you are

unable to pay your rent or utilities due to an unexpected medical cost, attach a copy of the medical bill.

 Authorization for the Release of Information (ROI). Household members over the age of 18 must sign the ROI.

 Documentation of all household members who are enrolled in a federally recognized tribe.

 You will be required to provide copies of all delinquent utility bills if applicable, or most recent bill.

 Documents showing unsafe or unhealthy living conditions.

 Documents showing other financial hardship.

 Driver’s license, state ID, or Tribal ID.

 Zero Income form if applicable.

Applicant Acknowledgements

I understand that I am required to update my application whenever any determining factor of eligibility changes. This

includes employment/annual income, contract information, no longer qualifying for unemployment benefits, no longer

experiencing a reduction in household income or other financial hardship, no longer facing a risk of homelessness or

housing instability, or having a household income that is above 80 percent of the Area Median Income for the

household.

By my signature below, I hereby certify that all of the foregoing information and attached documentation is true and

correct. I understand that providing any false statements, false information, any misleading statements or information,

or if I fail to notify of changes to my household’s eligibility, will be grounds for denial of the application or, if assistance

has already been granted, recapture of any funds granted, and may be grounds for civil or criminal prosecution if Nez

Perce Tribal Housing Authority determines it is appropriate to do so.

Disclaimer

The United States expressly disclaims any and all responsibility or liability to Recipient or third persons for the actions of

Recipient or third persons resulting in death, bodily injury, property damages, or any other losses resulting in any way

from the performance of this award or any other losses resulting in any way from the performance of this award or any

contract, or subcontract under this award.

The acceptance of this award by Recipient does not in any way constitute an agency relationship between the United

States and Recipient.

Funds provided by US Treasury for Low Income Families.

Signature:

Date:

Authorization for the Release of Information

Organization Requesting Release of Information:

Applicant Name:

Nez Perce Tribal Housing Authority (NPTHA)

PO Box 188

Lapwai, ID 83540

Address:

P: (208)843-2229

City, State, Zip Code:

E: nptha@nezperce.org

Purpose: In signing this consent form, you are authorizing the

abovenamed organization to request information including but not

limited to: identity and marital status, income and assets, public

assistance, residences and rental activity, and criminal history.

NPTHA needs this information to verify your eligibility for housing

assistance. NPTHA may participate in computer matching programs

with these sources in order to verify your eligibility and level of

benefits.

Uses of Information to be Obtained: NPTHA will protect the

information it obtains with appropriate and reasonable security

measures. NPTHA may disclose information (other than tax return

information) for certain routine uses, such as to other government

agencies for law enforcement purposes and to Federal and State

agencies for employment suitability, accuracy of information, and

fraud prevention purposes. NPTHA is required to protect the

information it obtains in accordance with any applicable privacy law.

NPTHA employees may be subject to penalties for unauthorized

disclosures or improper uses of the information that is obtained

based on this consent form.

Denial of eligibility may be subject to NPTHA’s grievance

procedures.

Sources of Information: The groups or individuals that may be

asked to release the authorized information include but are not

limited to:

Current and Previous Landlords (including Public Housing

Agencies)

Courts and Post Offices

Schools and Colleges

Law Enforcement Agencies

Support and Alimony Providers

Past and Present Employers

Welfare Agencies

State Unemployment Agencies

Social Security Administration

Who Must Sign the Consent Form: Each member of your

household who is 18 years of age or older must sign the consent

form. Also required to sign are those persons under age 18 who are

the head of household or co-head and are considered emancipated

minors.

Medical and Child Care Providers

Failure to Sign Consent Form: Your failure to sign the consent

form may result in the denial of eligibility for housing assistance.

Credit Providers and Credit Bureaus

Veterans Administration

Retirement Systems

Banks and other Financial Institutions

Utility Companies

Consent: I consent to allow NPTHA to request and obtain any information from any Federal, State, or local agency, organization, business,

or individual for the purpose of verifying my eligibility and level of benefits for housing assistance. By completing and submitting this form

I acknowledge that my types name shall have the same legal validity and enforceability as a manually executed signature to the fullest extent

permitted by applicable law.

Signatures:

Head of Household

Date

Spouse or Co-head

Date