Emergency Rental Assistance Program Application for tenants

Head of Household (HOH) Name(Required)

First Last

Household Address(Required)

Street Address Address Line 2 City State ZIP Code

HOH Phone Number(Required)

HOH Email

HOH Last Four Digits of SSN(Required)

Assistance Needed

Assistance needed for:(Required)

Overdue Rental Payments

Overdue Utility Payments

How Much do you owe in rental payments?(Required)

How Much do you owe in utility payments?(Required)

Which of the following utilities do you owe? (Check all that apply)(Required)

Water and/or sewer

Gas and/or Electric

Trash removal

Other energy costs, such as oil, natural gas, propane, etc. used for home heating

Have you applied for any energy assistance programs?

Yes

No

Hidden

Rental Ledger or Late Notice(Required)

Max. file size: 50 MB.

Rental Ledger and/or Late Notice(Required)

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Hidden

Water and/or Sewer Bill(Required)

Max. file size: 50 MB.

Water and/or Sewer Bill(Required)

Drop files here or

Max. file size: 50 MB, Max. files: 1.

Hidden

Gas or Electric Bill(Required)

Max. file size: 50 MB.

Gas and/or Electricity Bill(Required)

Drop files here or

Max. file size: 50 MB, Max. files: 1.

Hidden

Trash Removal Bill(Required)

Max. file size: 50 MB.

Trash Removal Bill(Required)

Drop files here or

Max. file size: 50 MB, Max. files: 1.

Hidden

Other energy Bill(Required)

Max. file size: 50 MB.

Other Energy Bill(s)(Required)

Drop files here or

Max. file size: 50 MB, Max. files: 1.

Have you received an eviction notice due to unpaid rent or utilities?(Required)

Yes

No

When is your eviction scheduled?

Have you previously applied for another Emergency Rental Assistance Program?(Required)

Yes

No

In what jurisdiction did you apply for the Emergency Rental Assistance Program?(Required)

If other, what jurisdiction did you apply for the emergency rental assistance program through?(Required)

COVID-19 Impact

COVID-19 must have impacted your income, assets, or expenses in order to receive assistance.

How has the COVID-19 pandemic (since March 2020) affected your household’s income or assets? (Check all that apply.)(Required)

If other COVID-19 impact to income or assets, describe here:(Required)

If you lost income during the COVID-19 pandemic, did you report this income loss to BRHP?(Required)

Yes

No

What additional expenses have you had due to the COVID-19 pandemic (since March 2020)? (Check all that apply)(Required)

If other increased expenses caused by the COVID-19 Pandemic, Describe here:(Required)

Tenant Self-Certification

The information provided in the application and self-certification form is collected to determine if my household is eligible to receive assistance provided through the Emergency Rental Assistance Program.

Tenants participating in the program and receiving ERAP funding are required to must agree to the following terms and conditions. Please certify the following statements:

Accuracy

I certify that all the information provided in this application is correct and complete to the best of my knowledge. This includes information regarding my household, income, housing instability, and COVID-19 Impact. I understand that providing false statements or information is grounds for termination of assistance and is punishable under federal and state law.

Do you agree to the above statements regarding application accuracy?(Required)

I agree

I disagree

Duplication of Benefits

I certify that my household has not received assistance from another program for the same costs that will be paid by the Emergency Rental Assistance Program.

Do you agree to the above statement regarding duplication of benefits?(Required)

I agree

I disagree

Use of Payment

I certify that any payment of Emergency Rental Assistance Program funds made directly to me for the purpose of paying rent or utilities will be used for the intended purposes. If I am unable to pay my landlord or utility company with the funds, I will contact the program to seek guidance on alternative uses of funds. I understand that not using funds for the intended purposes may disqualify me from future assistance

Do you agree to the above statements regarding information sharing?(Required)

I agree

I disagree

Use of Payment

I certify that any payment of Emergency Rental Assistance Program funds made directly to me for the purpose of paying rent or utilities will be used for the intended purposes. If I am unable to pay my landlord or utility company with the funds, I will contact the program to seek guidance on alternative uses of funds. I understand that not using funds for the intended purposes may disqualify me from future assistance

Do you agree to the above statements regarding use of payment?(Required)

I agree

I disagree

Rental and Utility Debt Accrual Timeline

I certify that the amount of emergency rental/utility assistance requested in this application was accrued on or after March 13, 2020.

Do you agree to the above statement regarding the timeline of the rental/utility debt requested?(Required)

I agree

I disagree

HOH Name(Required)

Signature(Required)

Date(Required)

Emergency Rental Assistance Program Application for Tenants

Emergency Rental Assistance Program Application for tenants

Assistance Needed

COVID-19 Impact

Tenant Self-Certification

Accuracy

Duplication of Benefits

Use of Payment

Use of Payment

Rental and Utility Debt Accrual Timeline

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