Landlord Incentive Request Form

Landlord Incentive Request Form

This form is provided to request eligible incentives through the Landlord Incentive Program. Funds are subject to availability. Submit this form with a signed lease at initial lease-up of unit and within 30 days of the vacancy date. Incentive payments will be paid within 30 days of the executed lease and Housing Assistance Payment contract.
Tenant Information
Name*

First NameLast Name
SSN (last four digits):
Program:*
Address of Unit:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Move In Date:*

MonthDayYear
Date
Vacate Date:

MonthDayYear
Date
Landlord / Unit Information
Landlord Name:*

First NameLast Name
Phone:*
Please enter a valid phone number.
Email*
example@example.com
Monthly Rent:*
Security Deposit:*
Eligible Incentives – Please check all that apply:*

First-Time LandlordHigh Opportunity AreasVacancy PaymentEmergency Housing Voucher
First-Time Landlord – HACC will offer a $500 incentive to new landlords who agree to lease a unit to a voucher holder. New landlords can earn the incentive for up to five (5) units for a total of $2,500.

High Opportunity Areas – HACC will offer incentives to landlords who lease units in high-opportunity areas. Incentives range from $500 - $1,500, based on the chart below.

Vacancy Payment – HACC will offer payments of up to one month’s contract rent to participating landlords who agree to re-lease their units to families on the voucher program.

Emergency Housing Voucher – HACC will offer a $1,000 incentive to landlords that lease a unit to an EHV recipient.
Corresponding Census Tracts for High Opportunity Areas Incentive:

PRESM	High - $1,500	Moderate/Middle - $1,000	Low - $500
East		54.01, 54.02, 55, 56, 57.01, 57.02
Central	11	5,12.01
North		7,9.01,10,110	2, 53
Far N & W	12.05, 12.06	8,9.02
Southwest	12.03, 12.04, 13.01, 13.02
Campus		14, 58	3.01, 3.02, 4.01, 4.02, 59, 60, 111
Rantoul		101, 102.04, 103
Mahomet	106.01, 106.02
Rural Area	104, 105, 106.04, 107, 108, 109

Certification
By signing this form, I certify that all of the information provided above is true, correct, and complete to the best of my knowledge, and will be relied upon for purposes of determining eligibility for the landlord incentive program.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Landlord Incentive Request Form

Tenant Information

Landlord / Unit Information

Corresponding Census Tracts for High Opportunity Areas Incentive:

Certification