Quality Housing Coalition Internal Use:

○ Phone
Date: Program Specialist: EPP ID:
○ In-Person

Maine Eviction Prevention Program Application

Send completed application along with the required documentation to:
Quality Housing Coalition (QHC), Eviction Prevention Program
PO BOX 4015, Portland, ME 04101
Email: evictionprevention@qualityhousingcoalition.org
If you have any questions, please contact QHC at (207) 242-1240.
Your application will not be processed until all the requested documentation is provided.
A. PRE-SCREENING
Are you a full-time resident of Maine? ☐ Yes ☐ No
Are you a renter or do you pay lot rent for a mobile home you own? ☐ Yes ☐ No
Is your rent subsidized or paid on your behalf by any state or government agency
such as a Housing Choice Voucher? ☐ Yes ☐ No
Do you owe your landlord past due rent? ☐ Yes ☐ No
Have you received a court ordered eviction notice or other official notice? ☐ Yes ☐ No
What is your preferred language?

B. APPLICANT INFORMATION - Please include identity documentation with your application. You may provide one of the
following: valid Maine driver’s license, valid Maine identification card, valid passport or passport card or valid U.S. Military ID.
Applicant First Name, Middle Name, Last Name, and Suffix (Jr., Sr., III, etc.)

Social Security Number Date of Birth

Primary Phone Email Address
What is your preferred method of contact? ☐ Email ☐ Phone ☐ Mail
If you have an email, do you want a log-in for the Online Portal? ☐ Yes ☐ No
Ethnicity Race Gender
☐ Hispanic or Latino ☐ American Indian or Alaska Native ☐ Native Hawaiian and Other Pacific Islander ☐ Female
☐ Not Hispanic or Latino ☐ Asian ☐ White ☐ Male
☐ Prefer not to answer ☐ Black or African American ☐ Mixed Race ☐ Other
☐ Prefer not to answer

C. PROPERTY INFORMATION – Please provide a signed lease or rental agreement that identifies the unit where the
household resides and the amount of rental payment or the pad/lot rental amount.
Property Address (Street, Town, State, and Zip) Number of Bedrooms in Unit

Mailing Address, if different from above (Street, Town, State, and Zip)

Landlord Name and Address (Street, Town, State, and Zip)

Landlord Email Landlord Phone

Rent Amount and Frequency (Monthly, Weekly) Is this Lot Rent? ☐ Yes ☐ No

Number of Months in Arrears Total Amount of Arrears Owed (including fees)

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D. HOUSEHOLD INFORMATION – If you do not have any other household members, please continue to Section E.
Household Member First Name, Middle Name, Last Name, and Suffix (Jr., Sr., III, etc.)

Relationship to Applicant

Social Security Number Date of Birth

Ethnicity Race Gender

☐ Hispanic or Latino ☐ American Indian or Alaska Native ☐ Native Hawaiian and Other Pacific Islander ☐ Female
☐ Not Hispanic or Latino ☐ Asian ☐ White ☐ Male
☐ Prefer not to answer ☐ Black or African American ☐ Mixed Race ☐ Other
☐ Prefer not to answer

Household Member First Name, Middle Name, Last Name, and Suffix (Jr., Sr., III, etc.)

Relationship to Applicant

Social Security Number Date of Birth

Ethnicity Race Gender

☐ Hispanic or Latino ☐ American Indian or Alaska Native ☐ Native Hawaiian and Other Pacific Islander ☐ Female
☐ Not Hispanic or Latino ☐ Asian ☐ White ☐ Male
☐ Prefer not to answer ☐ Black or African American ☐ Mixed Race ☐ Other
☐ Prefer not to answer

Household Member First Name, Middle Name, Last Name, and Suffix (Jr., Sr., III, etc.)

Relationship to Applicant
Social Security Number Date of Birth

Ethnicity Race Gender

☐ Hispanic or Latino ☐ American Indian or Alaska Native ☐ Native Hawaiian and Other Pacific Islander ☐ Female
☐ Not Hispanic or Latino ☐ Asian ☐ White ☐ Male
☐ Prefer not to answer ☐ Black or African American ☐ Mixed Race ☐ Other
☐ Prefer not to answer
Do you have additional household members? ☐ Yes ☐ No - If yes, attach an Additional Application Information Form
E. INCOME INFORMATION – Income is money or contributions paid to or for, someone in your home.
Please provide the current income received for all those living in your home. Please include documentation of each income
source by providing current pay stubs, tax return, benefit letter for the current program year, etc.
Name:
Name of Income Source:
Gross Amount Earned: $ ☐ Weekly ☐ Bi-Weekly ☐ Monthly
Name:
Name of Income Source:
Gross Amount Earned: $ ☐ Weekly ☐ Bi-Weekly ☐ Monthly
Name:
Name of Income Source:
Gross Amount Earned: $ ☐ Weekly ☐ Bi-Weekly ☐ Monthly
Does your household have additional income sources? ☐ Yes ☐ No -If yes, attach an Additional Application Information Form
☐ My household currently has no source of income
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 State of Maine Eviction Prevention Program: Applicant Attestation and Certification
I hereby certify, attest and affirm that my household is obligated to pay rent, which may include pad or lot rent for a mobile home,
on a residential Dwelling Unit in the State of Maine, which is my primary residence. Additionally, I affirm and attest that my
household meets the following criteria:
• Is at risk of eviction (for example: has past due rent notices, other correspondence from a landlord indicating
past due rent, or eviction notices due to rent owed)
• Has a past due rental amount at or below $19,200
• Does not receive a federal housing voucher to pay rent
• Is not living in a subsidized housing unit
• Has a current landlord-tenant relationship supported by a lease or other documentation
• Is not renting from a family member or is renting from a family member, but lives in a separate fully contained Dwelling
Unit and has a preexisting written lease and evidence of a history of consistent rental payments
• No member of my household is on the deed or a signer or co-signer on a mortgage or has exercised an option to
purchase the property for which I am requesting assistance

Under penalty of perjury, I certify, attest and affirm that all of the information I have provided in connection with this Application,
including the information presented above, is complete and accurate to the best of my knowledge and belief. I authorize Maine
State Housing Authority and the State of Maine to verify and investigate such information with my full cooperation at any time. I
understand that if I fail to cooperate, I may be required to repay funds received and may be ineligible for future payments. I
understand that Maine State Housing Authority may randomly select applications and request supporting documentation.
I further understand that providing an intentionally false or inaccurate representation herein constitutes an act of fraud. Providing
false, misleading, or incomplete information may result in 1) my obligation to repay any and all funds received through the Maine
Eviction Prevention Program and/or 2) imposition of federal, state, and local criminal and civil actions for fines, penalties,
damages or imprisonment or any other remedies allowable under applicable law.
I am formally submitting this written attestation and certification and understand that the Maine Eviction Prevention Program is
relying upon this attestation as part of the review process for determining whether my household is eligible for the program.
By entering my name below and submitting this form, I am acknowledging that I have read and understand this attestation and
certification and that I am providing full and truthful information above.

I am signing this Application & Attestation by electronically entering my name below or providing a wet signature.
Applicant Signature: Date:

Printed Name:

Maine State Housing Authority (“MaineHousing”) does not discriminate on the basis of race, color, religion, sex, sexual
orientation, national origin, ancestry, physical or mental disability, age, familial status or receipt of public assistance in the admission
or access to or treatment in its programs and activities. In employment, MaineHousing does not discriminate on the basis of race,
color, religion, sex, sexual orientation, national origin, ancestry, age, physical or mental disability or genetic information.
MaineHousing will provide appropriate communication auxiliary aids and services upon sufficient notice. MaineHousing will also
provide this document in alternative formats upon sufficient notice. MaineHousing has designated the following person responsible
for coordinating compliance with applicable federal and state nondiscrimination requirements and addressing grievances:
Lauren Bustard, Maine State Housing Authority
26 Edison Drive, Augusta, Maine 04330-6046,
Telephone Number 1-800-452-4668 (voice), (207) 626-4600 (voice) or 711 (Maine Relay)

This is not a case management program and Program Specialists are not able to assist outside of eligibility determination. If
you need additional assistance, please reference the resource guide at www.evictionprevention.mainehousing.org.

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