Fillable EBR ERAP Appeal Form Please describe in detail (EBR Emergency Solutions)

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EBR ERAP Appeal Form Please describe in detail (EBR Emergency Solutions)

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The EBR ERAP Appeal Form Please describe in detail (EBR Emergency Solutions) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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V1 5-25-2021
Page 1 of 2
EBR ERAP Appeal Form
Applicant Full Name: Applicant ID #: ___________________________
Applicant Property Address:
Applicant Phone Number: ________________________________ Email: __________________________________________
Please describe in detail your appeal, all relevant facts and dates, and the names of individuals involved
or the names of those who may have relevant information:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Applicant Signature: _________________________________________________ Date: ______________________________
Please email the completed form to the EBR ERAP at support@ebremergencysolutions.zendesk.com so
your appeal can be assigned to an ERAP Team Supervisor.
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V1 5-25-2021
Page 2 of 2
FOR ERAP STAFF USE ONLY
Date Received: ________________ Staff Person Assigned to Appeal: ______________________________________
Resolution: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Additional Comments: _____________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
ERAP Staff Signature: ___________________________________ Date Resolved: ___________________________________
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EBR ERAP Appeal Form Please describe in detail (EBR Emergency Solutions)

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Completed 9 August 2021

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