Language
English (US)
Spanish (Latin America)
Renter Application
Cambie el idioma del formulario usando el botón en la parte superior derecha del formulario. Change the form language using the button at the top right of the form.
If you have already received the maximum months of assistance, you are not eligible for assistance.
Visit https://www.ceopeoplehelpingpeople.org/covidrentrelief for more information on the maximum months of rental assistance.
The Emergency Rental Assistance Program provides assistance to Luzerne County households that are unable to pay rent due to the COVID-19 Pandemic. Please review eligibility requirements and an overview of the application process on our website before completing this application: www.ceopeoplehelpingpeople.org/COVIDrentrelief.
Only rental households are eligible for assistance. Homeowners are not eligible.
You must have the following information available to you to upload pictures or documents as part of this application. You will not be able to submit an incomplete application, but you can save the application and come back to it later using the link sent to your email.
1. Proof of all household income, from all sources. 2. Photo ID for all adults in the household. 3. Proof of Address (in addition to photo ID - document must contain your name and address) You or your landlord must provide the following (not required for submission of this application, but is required before processing/reviewing your application): 1. Lease or Property Certification for Verbal Leases 2. Proof of your last rental payment, if you are requesting rental assistance.
If you are ready to start the application, please click next. If you do not have all of the information noted above, please gather the info needed and start the application later.
Back
Next
Save
Renter Information
Renter's Name
*
First Name
Middle Name
Last Name
Suffix
Has anyone in your household received assistance through the Emergency Rental Assistance Program?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What County do you live in?
*
Luzerne
Wyoming
Other
You have indicated that you do not reside in Luzerne County.
This application is for Luzerne County Residents only. You can find out how to apply for assistance in other counties by visiting this website: https://www.compass.state.pa.us/Compass.Web/RAP/Application Please note, CEO does process Wyoming County applications, but they must be submitted through the state application system linked above.
Phone Number
*
Email
*
example@example.com
Lease Start Date (or move-in date if you do not have a lease):
*
-
Month
-
Day
Year
Date
Lease End Date (leave blank if you do not have a lease):
-
Month
-
Day
Year
Date
Amount of monthly rent.
Back
Next
Save
Request for Assistance
Please note: A maximum of 3 months of rent can be requested.
Please list the months of rental arrears you are requesting and the amount of rent assistance requested for each month. DO NOT INCLUDE ANY FUTURE MONTHS.
*
Month & Year
Rent amount
1
2
3
Has anyone in your household received subsidized rental assistance for the months noted above?
*
No
Yes, list the source of assistance under "Other" below.
Other
Are you requesting assistance with overdue utilities, such as heat, electric, gas, or water? Check all that apply. Please note, the last day to apply for utility assistance is 11/30/2022.
No
Yes, I am applying for overdue utility assistance only, not rent.
Yes and I have a shut-off notice for one or more utility.
Yes, please name the utility companies under "Other" below:
Other
If you are requesting overdue Utility Assistance, have you applied for any other programs such as LIHEAP, LIHEAP Crisis, or a Customer Assistance Program?
I am not applying for Utility Assistance
No, I have not applied to any other programs for utility assistance
Yes, I have applied for other utility assistance and am waiting on approval
Yes, I have been approved for other Utility Assistance
I applied but was denied other Utility Assistance
If you are facing a shut-off for heating fuel, please apply for the LIHEAP Crisis program immediately. The LIHEAP program is equipped to handle emergency applications to prevent shut-off or to quickly re-establish service. The COVID Emergency Rent and Utility Program is currently handling a high volume of applications and may not be able to review and approve your application quickly enough to prevent a utility shut-off. Find out more: by visiting: www.ceopeoplehelpingpeople.org/crisis
I understand that this program may not be able prevent shut-off of my utilities or quickly re-establish service.
Back
Next
Save
Landlord Information
If your landlord is not aware that you are applying for this program, please notify them as they will be contacted by a program representative.You must ask your landlord to complete the application and provide the documentation outlined below:1) Landlord Application, 2) Provide proof of ownership, 3) Provide a completed W-9 form. All of this can be accessed online: www.ceopeoplehelpingpeople.org/covidrentrelief
Landlord Name:
*
Landlord Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Landlord Phone Number:
*
Landlord Email Address (if available):
Back
Next
Save
Household Information
Total number of permanent household residents (adults and children):
*
For the head of household only: What is your sex?
*
Male
Female
Non-Binary
Prefer not to say
For the head of household only: What is your ethnicity?
*
Hispanic or Latino
Not Hispanic or Latino
Prefer not to say
For the head of household only: What is your race?
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
Are you a Veteran?
Yes
No
Back
Next
Save
Income and Eligibility
Has anyone in your household experienced financial hardship during the COVID-19 Pandemic? Check all that apply.
No
Yes, a period of unemployment
Yes, a decrease in income
Yes, increase in household costs such as utilities or childcare (please describe below)
Other, please describe below:
Other
You indicated that no one in your household experienced financial hardship due to COVID. This makes you ineligible for assistance.
If you have not faced any financial hardship due to COVID you may be eligible for assistance through another CEO program. Please contact CEO by phone for further assistance: 570-826-0510.
Employment Status - check all that apply:
*
Someone in the household qualifies for unemployment benefits as a result of the COVID-19 Pandemic.
Someone in the household is currently unemployed and has been unemployed for less than 90 days
Someone in the household is currently unemployed and has been unemployed for 90 days or more
None of the above
Does anyone in your household have income? (including earned income like wages and tips and unearned income like child support, social security retirement or disability, unemployment, etc...)
*
Yes
No
List the name and age of EVERYONE in the household, including children. List first and last names. Add income information for anyone with income, but you must list all household members' names and ages regardless of income.
*
Full Name
Age
Income source (i.e. work, retirement, SSI, SSD, child support)
Income amount ($)
How often paid? (weekly, bi-weekly, monthly)
Date of most recent payment
1
2
3
4
5
6
7
8
Back
Next
Save
1. If you have had no income in the past 30 days, please complete this Zero Income Form:
I state that no member of my household has received any source of income during the past 30 days.
First Name
Last Name
My household consists of (list of family members) - first and last names:
My household has been without income since:
-
Month
-
Day
Year
Date
I expect to receive some income on or about:
-
Month
-
Day
Year
Date
List expected source of income:
Please indicate how your household is meeting its needs for the following items:
Please describe how you meet these basic needs without income:
Food:
Shelter:
Gas Service:
Electric Service:
Water Service:
Phone, including cell phone:
Transportation:
Add any other details about how you meet your basic needs:
Signature, confirming zero income in the household for the past 30 days.
*
Back
Next
Save
You must upload the following documentation:
1. Documentation of ALL gross income, either your income* from past 30 days prior to application date or a copied of your filed 2020 Tax Return (IRS 1040). W-2s are NOT allowable proof of income.
*Income includes earned income (i.e. income statements, letter from employer, paystubs) and unearned income (i.e. child support, pensions, social security retirement or disability (SSD), supplemental social security income (SSI), TANF, unemployment compensations, utility reimbursements, Veterans Disability, Veterans Pension, Workman's Comp).
Please upload proof of income documents here. You can upload multiple files or photos:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
2. Photo identification for ALL adults in the household
Please upload pictures of the front and back of everyone's photo ID. Please upload the front then the back for each person so we can match them up. You can upload multiple photos:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
3. Proof of address. Please provide a copy of another document that verifies your name and home address.
Examples of acceptable documents include: utility bill, car insurance, vehicle registration, school or medical mail, other bills like phone or internet. Your photo ID (submitted above) is not acceptable as the only proof of address.
Upload your proof of address
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
4. A copy of your full written lease or the form, Landlord & Tenant Property Certification for Verbal Leases. All pages must be submitted.
If you do not have this, your landlord can submit it with their application. Please note, your application cannot be considered for assistance until this is provided.
Upload your lease or Property Certification for Verbal Leases, if you have it.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
You can download a copy of the Landlord & Tenant Property Certification for Verbal Leases. If you cannot see the form in the box below, please click the open button in the top right corner to view it in a new tab.
Puede descargar una copia de la Certificación de propiedad de propietarios e inquilinos para arrendamientos verbales. Si no puede ver el formulario en el cuadro a continuación, haga clic en el botón Abrir en la esquina superior derecha para verlo en una nueva pestaña.
5. Documentation must be submitted showing the last payment made by the tenant. The documentation provided must include the tenant’s name, date and amount of last payment, and a check number if payment was made by check.
Acceptable documentation can include a cancelled check, payment ledger, dated and signed rent receipt or other documentation acceptable at the discretion of CEO. If you have a rent receipt or cancelled check, you can upload it now. If not, your landlord will be required to provide this information. **Please note, your application cannot be considered for assistance until this is provided.**
Upload proof of last rental payment.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
6. If you are requesting utility assistance, you must provide a copy of the bills* you are requesting assistance with.
You will need to provide copies of every month from when you started falling behind until now or an account statement breaking down your monthly bills. *If you are applying for UGI assistance, you must request your AR Statement from UGI and submit that in place of copies of your bills. Payment on UGI accounts cannot be made without the AR Statement.
Upload your utility bills.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If approved, do you agree to provide updated information, including but not limited to income documentation for all sources of income, prior to payment of any future rental assistance?
*
Yes
No
Back
Next
Save
Certifications
By initialing below, I attest that I have and will continue to occupy the residence for every month of assistance for which I am applying
Initials
*
By initialing below, I attest that one or more of the following is true, during the COVID-19 Pandemic: 1. I am delinquent in my monthly rent or utilities 2. I am at risk of being evicted or having a utility shut-off 3. I am at risk of becoming homeless or at risk of housing instability
Initials
*
By initialing below, I attest that my household has experience financial hardship which may include, but is not limited to, a period of unemployment, a decrease in household income or had increased household costs during the COVID 19 Pandemic.
Initials
*
Applicant Certification
I am an applicant under the Emergency Rental Assistance Program and hereby certify the following:That the information provided by me on the application for assistance under the Emergency Rental Assistance Program is true and correct.That I understand the requirements of the program and agree to abide by those requirements.That all assistance provided will be used in compliance with the terms of the program.By my signature below I hereby certify that the above statements are true and correct. I further understand that should any of my above statements be found to be false it will preclude my eligibility for assistance, or continued assistance, under the Emergency Rental Assistance Program.
Applicant Signature
*
By signing below, you are agreeing to the following statement: "I acknowledge that all information and documentation provided are correct and complete and I understand that providing a written false statement which I do not believe to be true is a misdemeanor of the third degree and is punishable as perjury under Pennsylvania Title 18, Section 4904, related to unsworn falsification to authorities, and that in addition to any other penalty that may be imposed, a person convicted under this section s hall be sentenced to pay a fine of at least $1,000."
Signature
*
Social Security Number
Today's Date
-
Month
-
Day
Year
Date
Submitting Your Application: Please note, completing this form does not guarantee assistance.
Please allow up to two weeks for processing your application.
After submission of this form, to complete your application you must:
Notify your landlord that information must be supplied by them before CEO can issue rental payments on your behalf. Refer to CEO's website: www.ceopeoplehelpingpeople.org/COVIDrentrelief for additional information and landlord forms. Email us at ceorentrelief@gmail.com.If you have questions about this application or submitting your documents, please call: 570-826-0510 and ask for the COVID Emergency Rent and Utility Assistance program.
Save
Submit
Should be Empty: