Rent/Mortgage Assistance Application

Section 3: Rental Assistance Housing Information

I certify by completing this section that I am or anticipate being behind on my rent and experiencing a housing crisis and facing potential homelessness due to loss of income when COVID-19 restrictions were imposed by the Metro Nashville & the State of Tennessee.
Name of apartment complex *
Property Manager/Company Name *
Property Manager Phone Number *
Property Manager Email
Lease Start/End Date *
$ Amount of Monthly Rent *
Date Rent Became Delinquent
$ Amount of Total Rent Arrearage
$ Amount of Late Fees/ Interest Charges
Has an Eviction Notice Been Received? *

Yes No
Date of Notice and Effective Date of Eviction
Are You Currently Receiving Any Type of Housing Assistance? *

Yes No
If yes, Indicate Which Type of Housing Assistance You Are Receiving:

Public Housing Housing Choice/Section 8/ or Other Voucher

Section 5 - Financial Hardship Questionnaire/ Screening Questions
As of January 1, 2020, I was employed *

Full-time (32 hours/week – can be from multiple employers) when COVID-19 restrictions were imposed by Metro Nashville & the State of Tennessee Part-time (less than 32 hours/week) when COVID-19 restrictions were imposed by Metro Nashville & the State of Tennessee
Please read carefully and select the response that best describes your current situation: *

I have already regained employment and have sufficient income to resume making rent/mortgage payments after assistance is provided. My employer(s) has guaranteed my return to employment once COVID-19 restrictions are fully lifted and I am currently receiving unemployment compensation and have sufficient income to resume making rent/mortgage payments after assistance is provided. My employer(s) has contacted me to return to work and has guaranteed return to my previous position and scheduled hours and I anticipate having sufficient income to resume making rent/mortgage payments after assistance is provided until I am able to return to work. My employer(s) has not guaranteed my return to employment, but I anticipate having sufficient income from other sources to resume making rent/mortgage payments after assistance is provided. My employer(s) has not guaranteed my return to employment and at this time, I do not know if I will be able to resume making rent/mortgage payments after assistance is provided.
Date expected to return to work:
COVID-19 has affected my household in the following ways: *

Section 7 - Asset Self-Certification

ASSETS are defined as funds available/accessible to the applicant/co-applicant and includes money in savings, checking accounts, bonds, stocks, bonds, CDs, IRAs, 401k, surrender value of life insurance, equity in real estate (other than your primary residence), etc. Please check/complete the category below that best describes the value of your assets.
The $ value of my household assets is: *

Less than $5,000 Above $5,000
Approximate Value of Assets *

Section 8 - Adults or Children Living In the Household
Total Number of People Living In the Home: *

List all current household members below. Indicate relationship of each member to the applicant(spouse, sibling, etc.).:

First Name

Last Name

Age

Gender M/F

Relationship

Family Member

Section 9 - Anticipated Annual Household Income Information

PLEASE ENTER THE AMOUNT OF ANTICIPATD GROSS (BEFORE TAXES) ANNUAL INCOME for each household member 18 or older in the appropriate category in the table below:

Income Source

APPLICANT

CO-APPLICANT

OTHER HOUSEHOLD MEMBER 18 or OLDER

TOTAL

Salary

Overtime, commission, tips, bonuses

Alimony, Child Support

Pensions, retirement

Unemployment, Workers Comp

Business Net Income

Rental property net income

Welfare payments

Interest and/or dividends

TANIF/ WIC

COVID-19 Payroll program - or rent/mortgage assistance

Other

Section 10 - Applicant (s) Signature/Certification

By signing below, I/we certify that the information provided in this application is accurate and complete and that we are residents of Nashville-Davidson County. I/we further acknowledge that eligibility for services funded through the CDBG-CV program is based upon having a qualifying annual family income level, and that the income level and/or status I have indicated in this self-certification is subject to further verification by the agency providing services, MDHA and/or HUD. I/we acknowledge that meeting program eligibility requirements does not guarantee assistance will be provided. I/we acknowledge and understand any false statements or false information made on this application will result in immediate denial of my/our application for this program. I/we will provide documentation of all income sources upon request. I further understand that by signing, all information gathered about me and my household is personal and private and I authorize, Martha O’Bryan Center, to enter all household information into Charity Tracker.
Applicant's Signature

Clear
Date

Month Day Year
Date
Co-Applicant's Signature

Clear
Date

Month Day Year
Date
Should be Empty:

NASHVILLE-DAVIDSON COUNTY COVID-19 APPLICATION FOR CDBG-CV RENT/ MORTGAGE ASSISTANCE

Eligibility Requirements

Ineligible Participants – General Criteria:

Section 1: General Information

Section 2: Demographic Information

Section 3: Rental Assistance Housing Information

Section 4: Mortgage Assistance Housing Information

Section 5 - Financial Hardship Questionnaire/ Screening Questions

Section 6: Income Self Certification

Section 7 - Asset Self-Certification

Section 8 - Adults or Children Living In the Household

Section 9 - Anticipated Annual Household Income Information

Section 10 - Applicant (s) Signature/Certification