Statement of Delinquent Rent
Tenant Name: __________________________________
Address of Rental Unit: __________________________
This notice is to inform you that I have not received rent due for the months of:
____ March 2020 (Note: The GRA will not provide assistance for any period prior to March 13,
____ April 2020
____ May 2020
____ June 2020
____ July 2020
____ August 2020
____ September 2020
____ October2020
____ November 2020
____ December 2020
____ January 2021
____ February 2021
____ March 2021
1) The base rent amount not paid for the months checked above is $ _________
2) Late fees applied to the unpaid rent total $ _____________
(Note: The GRA program will not pay late fees that exceed 8% of the total past due rent. You will be required to
waive any late fee above the percentage allowed.)
3) Total Amount of past due rent and late fees requested: $_________
I, _____________________(Landlord) certify that the amounts listed above is what I am owed
for ____________________(Tenant) residing at ______________________________________
______________________________________________ (Street Address, City, State, Zip Code).
I affirm that all the information is true, correct and complete to the best of my knowledge.
In signing this statement (including electronic signature) you are acknowledging that falsification
of documents or any material falsehoods or omissions in the Application, including knowingly
seeking duplicative benefits, is subject to state and federal criminal penalties. You are particularly
put on notice that 18 U.S.C. §1001 provides, among other things, that whoever knowingly and
willingly makes or uses a document or writing containing any false, fictitious, or fraudulent
statement or entry, in any matter within the jurisdiction of any department or agency of the
United States will be fined not more than $10,000 or imprisoned for not more than five years, or
____________________ ______________
Landlord Signature Date
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