LANDLORD APPLICATION - Lake County Rental Assistance (LCRA) Application

Lake County Rental Assistance - Landlord Application Form
Instructions:
The Lake County Rental Assistance (LCRA) Program is available for eligible renter households in Lake County, IL that have been impacted by COVID-19. Payments are made directly to a household’s landlord on behalf of the household. Households must submit a complete application and be determined eligible in order for landlords/property managers to receive assistant payments.

This Landlord Application Form is required for a landlord to receive a LCRA rent payment on behalf of an eligible tenant. This form does not guarantee assistance. Before you fill out and submit this form, make sure you speak with your tenant and confirm that they are submitting a LCRA Application Form.

This form must be completed by the landlord, property manager, or property owner. You will be asked to attach a W-9. If you do not have a W-9, please click here to download a blank W-9 form. If an electronic payment is desired, you may also fill out the ACH form. Filling out an ACH form does not guarantee an electronic payment.

Section 1: Contact Information

Your contact information will be used to contact you about your application. Please use a phone number and email address where you can be reached.
Property Owner Name *

First Name Last Name
Landlord/Property Manager Name (can be same as property owner name) *

First Name Last Name
Property Management Company (If applicable)
Landlord/Property Manager or Management Company Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Landlord/Property Manager or Management Company Phone Number *
Please enter a valid phone number.
Landlord/Property Manager or Management Company Email *
example@example.com

Section 2: Unit Information

The following information is about the unit for which your tenant is applying for assistance.
Tenant Name *

First Name Last Name
Tenant Application ID Number
This number can be found on the email sent to you when your tenant submitted their application
Tenant Email *
example@example.com
Tenant Phone Number *
Please enter a valid phone number.
Address of Rental Unit *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Number of Bedrooms in Rental Unit Listed Above
Monthly Amount
Does your tenant have a lease?

No Yes
Are you the property owner, who is obligated to pay property taxes on this property?

No Yes
The person who is obligated to pay property taxes on this property must sign the Rent Obligation Form. If you are not the property owner, please close this form and have the property owner fill out and submit this form.
Landlord Rent Obligation Attestation Form

Instructions: This Rent Obligation Attestation Form fulfills the requirement of LCRA eligibility criteria 1: the household is obligated to pay rent on a residential dwelling.
This form may only be used to fulfill the requirement if the applicant does not have a written lease. If the applicant has a written lease, the applicant MUST submit the lease and this form SHOULD NOT be submitted.

The property owner must sign this form.

Property Owner Name:{propertyOwner}

Landlord/Property Manager Name:{landlordpropertyManager}

Landlord/ Property Manager Address:{landlordpropertyManager9}

Phone#: {landlordpropertyManager10}

Email:{landlordpropertyManager48}

Monthly Rent Amount:{monthlyAmount}

By signing below, the undersigned certifies to the following:
- The tenant listed above and I, the property owner, have an agreement for the tenant to reside in the property in exchange for the monthly rent amount entered above.
- The tenant listed above and I, the property owner, do not have a signed lease and have otherwise entered into an agreement.
- The undersigned confirms that the above information is true and accurate to the best of his or her knowledge and that providing false representations herein constitutes as an act of fraud.
Date

Month Day Year
Date
Signature

Clear

Section 3: Additional Information
Lease or Rental Agreement Start Date *
Lease or Rental Agreement End Date (If no end date, enter "none") *
Is the tenant in arrears *

No Yes
How much does the tenant owe?
Is any of the owed amount due to late fees?

No Yes
How much in late fees is owed?
Please breakdown the amount owed by month.
Are you currently receiving any other form of rental assistance for this household? *

No Yes
Please describe the other assistance you receive for this household.
If this household is receiving support from Lake County Housing Authority, what is the amount you receive?

Section 4
How do you wish to receive payment

Electronic Funds Transfer (this is for informational purposes only. Not all providers are able to provide electronic transfers.) Check mailed to the landlord/property manager/management company listed above
Lake County LCRA ACH Credit/Debit Authorization Form
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I (we) hereby authorize {pleaseSelect} (THE COMPANY) to initiate entries to my (our) {name} checking/savings accounts at the financial institution listed below (THE FINANCIAL INSTITUTION), and , if necessary, initiate adjustments for any transactions credited/debited in error. The authority will remain in effect until THE COMPANY is notified by me (us) in writing to cancel it in such time as to afford THE COMPANY and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it.
Name of Financial Institution
Address of Financial Institution

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Set Amount or
Maximum Amount
Account Type

Business Account Personal Account
Financial Institution Routing Number
Checking/Savings Account Number
These numbers are located on the bottom of your check as follows:
Date

Month Day Year
Date
Signature

Clear
What name should the check be made to?
Optional
Please upload your W-9

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Cancel of
The undersigned certifies that to the best of his or her knowledge the apartment referenced above contains no health or safety violations that threatens the health or safety of the tenant.

The undersigned certifies that they have not received rent payments, from a FERA or LCRA provider or any other program, that covers the unpaid rent listed above.

The undersigned agrees that they will not evict the tenant, provide the tenant with a five-day notice, or in any way ask the tenant to leave for the nonpayment of rent, for the duration of this assistance. The undersigned agrees that if the tenant is facing eviction, the undersigned will only accept payment arrears if the eviction will be avoided.

The undersigned agrees to accept LCRA’s maximum late fee or the stated late fee in the lease, whichever is less. Any late fees for the months paid by LCRA that are above the maximum assistance will be forgiven.

The undersigned acknowledges that the tenant in the unit described above must be eligible for assistance and provide documentation in order to qualify for FERA assistance.

The undersigned confirms that the above information is correct and complete to the best of his or her knowledge and that providing false representations herein constitutes an act of fraud.
Name

First Name Last Name
Title
Signature

Clear
Should be Empty:

Lake County Rental Assistance - Landlord Application Form

Section 1: Contact Information

Section 2: Unit Information

Landlord Rent Obligation Attestation Form

Section 3: Additional Information

Section 4

Lake County LCRA ACH Credit/Debit Authorization Form