Tenant Form
Renters, please also be prepared to provide the following: Proof of income (a month's worth of paystubs), lease agreement, proof of residency (utility bill or other bill with your name and address on it), Photo ID, Supplemental Intake, Self-Declaration Form.
Landlord Information
Landlord Name
Address
Street Address
City
State/Province
Zip Code
County
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email (If Available)
example@example.com
Renter Household Information
Lessee(s) Name:
Lessee Address
Street Address
City
State
Zip Code
County
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Lease Effective Dates
-
Month
-
Day
Year
Start Date
End Date
-
Month
-
Day
Year
End Date
Number of Permanent Household Residents
Monthly Rent Amount ($)
ex: $1400
Amount of Late/Missed Rent (rent due before March 1, 2020 is not eligible)
List month(s) with late/missed rent payments between March 1, 2020 and Dec. 31, 2021:
1. Are monthly rent payments split between more than one lessee?
Yes
No
2. Do you have either a written or oral lease agreement with your landlord?
Yes
No
3. Have you and/or your landlord provided a lease agreement (written) and included a third-party document that can be used to verify residency for each lessee requesting funding assistance (i.e. utility bill, cancelled check with address, pay stub or ID showing the current residence address)? Please include third-party supporting documentation for both written and oral lease.
Yes
No
4. Do you attest that you either have or will continue to occupy that residence for every month which funding assistance funds are being applied?
Yes
No
5. Is the rent split between more than one lessee? If yes, how are the payments split between lessees? Lessee # 1 Name:
Lessee #1 Name
Amount of monthly rent paid by Lessee #1:
Lessee #2 Name:
Amount of Monthly rent paid by Lessee #2:
Lessee #3 Name:
Amount of Monthly Rent paid by Lessee #3
Lessee #4 Name
Amount of monthly rent paid by Lessee #4
6. Did you become unemployed after March 1, 2020 as a result of the COVID-19 pandemic?
Yes
No
7. What was the date of seperation from your employer?
-
Month
-
Day
Year
Date
8. Have your work hours or wages been reduced as a result of the COVID-19 pandemic?
Yes
No
9. Have you provided documentation for all sources of lessee income?
Yes
No
10. Are you able to provide documentation to verify unemployment with the Department of Labor and Industry's Bureau of Unemployment Compensation?
Yes
No
11. If approved to receive funding assistance, do you agree to provide updated income documentation for all source of income prior to payment of funding assistance of future rental assistance to the landlord/property owner of your behalf? Updated income documentation should be provided to the designated organization within ten (10) days of the first payment of new employment
Yes
No
Applicants that do not possess or are not eligible for a social security number may apply for benefits through submission of a valid Individual Tax Identification Number (ITIN) in lieu of a Social Security Number. Submitting an ITIN is not acceptable for unemployment verification purposes. Lessees that cannot by verified by the Department of Labor and Industry's Bureau of Unemployment Compensation may still be eligible for funding assistance if the lessee qualifies based on loss of income. If approved, lessee benefitting from funding assistance will be released from any obligation to pay any past due or future rent for the months which funding assistance funds are being applied. There shall be an agreement to not begin any eviction proceeding during the time covered by the rental assistance. Funding for this program will allow payment for the future rent, but only for 3 months of future rent at a time and will be reviewed thoroughly. Additionally, there funding will not exceed the monthly rental payment.
Lessee # 1 Name
Lessee # Signature
Lessee Social Security Number
Date
-
Month
-
Day
Year
Date
Lessee # 2 Name
Lessee #2 Signature
Lessee #2 Social Security Number
Date
-
Month
-
Day
Year
Date
Lessee #3 Name
Lessee #3 Signature
Lessee #3 Social Security Number
Date
-
Month
-
Day
Year
Date
Lessee #4 Name
Lessee #4 Signature
Lessee #4 Social Security Number
Date
-
Month
-
Day
Year
Date
Demographic Info
The following information is requested by the Federal Government for certain types of programs related to a dwelling in order to monitor compliance with equal credit opportunity, and fair housing. You are not required to furnish this information, but are encouraged to do so. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation.
Do you wish to provide this information?
Yes
No
Sex
Male
Female
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Race
American Indian or Alaska Native
Asian
White
Black or African American
Native Hawaiian or Other Pacific Islander
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