• Rental Assistance Program Application

  • STAFF ONLY

  • REF# RECEIVED BY DATE
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  • Applicant

  • Co-Applicant

  • FAMILY MEMBER INFORMATION

  • (Applicant & Co-Applicant will be required to provide 3 months of bank statements)

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  • AMI 0‐30% >30‐50% >50‐80% Over 80%

  • HOUSING & EMPLOYMENT INFORMATION

  • Please be note that we will contact your Property Manager and Employer for additional information and documentation.

  • By checking one of the statements below—You may be required to provide proof to document the statement.

  • FINANCIAL HARDSHIP QUESTIONNAIRE/SCREENING QUESTIONS

  • Please complete the requested information and place a check mark next to the statement that
    most closely reflects your current situation since the COVID‐19 Disaster Declaration

  • A. EMPLOYMENT

    COMPLETE REQUESTED INFORMATION AND CHECK ALL THAT APPLY
    A determination of financial hardship due to lost employment or income either permanently or temporarily due to the effects of the COVID‐19 pandemic.

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  • B. HOUSING (Rental Assistance)

    COMPLETE REQUESTED INFORMATION AND CHECK ALL THAT APPLY
    A determination of housing crisis due to lost employment or income either permanently or temporarily due to the effects of the COVID‐19 pandemic.

  • I am experiencing a housing crisis and facing potential homelessness due to loss of income when COVID‐19 Shelter‐in‐Place was institut‐
    ed. My monthly rent payment is $ and is due on (day and month)

  • 1. I owe back rent for a total of months, and the total amount of $ for rent past due PRIOR to the COVID‐19 Shelter‐in‐Place being instituted.

  • 2. I owe back rent for a total of months, and the total amount of $ for rent past due AFTER the COVID‐19 Shelter‐in‐Place was instituted.

  • 3. owed in the amount of $ PRIOR to March 16, 2020 and $ AFTER March 16,2020 .

  •  
  • **QUESTIONS “C” THROUGH “G” ARE OPTIONAL (for informational purposes only)**

  • C. UTILITIES
    A determination of hardship and inability to pay for basic utilities due to lost employment or income either permanently or temporarily due to the effects of the COVID‐19
    pandemic. Basic Utilities include: Water, Electric, Gas

    CHECK ALL THAT APPLY

  • D. CHILDCARE
    A determination of hardship and inability to pay for proper child care due to lost employment or income either permanently or temporarily or day care is closed due to
    the effects of the COVID‐19 pandemic. Childcare is for a child/children age 0‐12 years of age.

    COMPLETE REQUESTED INFORMATION AND CHECK ALL THAT APPLY

  • E. FOOD
    A determination of financial hardship and inability to pay for an adequate amount food due to lost employment or income
    either permanently or temporarily due to the effects of the COVID‐19 pandemic.

     

  • F. TRANSPORTATION
    A determination of hardship and inability to pay for transportation to access certain necessary services due to lost employ‐
    ment or income either permanently or temporarily due to the effects of the COVID‐19 pandemic. Necessary services in‐
    clude: grocery stores, pharmacies, child care, employment.

     

  • G. HEALTH/MEDICAL/PRESCRIPTIONS
    A determination of hardship and inability to pay for medical/prescriptions due to lost employment or income either perma‐
    nently or temporarily due to the effects of the COVID‐19 pandemic. . Childcare is for a child/children age 0‐12 years of age.

  • AUTHORIZATION FOR RELEASE OF INFORMATIONSELF CERTIFICATION STATEMENT OF ANNUAL INCOME BY BENEFICIARY

  • I declare under penalty of perjury that the information provided in this application is true and accurate to the best of myknowledge. I understand that willfully and knowingly making a false or fraudulent statement on this application is a felony thatmay be punishable by jail time and/or a fine. I also understand that the information provided on this form is subject to verifica-tion by the City of Vista and the United Stated Department of Housing and Urban Development at any time.All household members age 18 years and over

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