Fillable Application for COVID-19 Rental/Utility Assistance City of Greensboro

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Application for COVID-19 Rental/Utility Assistance City of Greensboro

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1
City of Greensboro CARES Act
Application for COVID-19 Rental/Utility Assistance
Type of Assistance
Assistance is available to qualified households towards emergency monthly rental/utility assistance
for their primary residence. Rental assistance is limited to a maximum benefit of $1,500 per
household. Utility assistance is limited to a maximum benefit of $400 per household.
Please note this program provides rental and utility assistance only. Assistance with other housing
expenses including repairs, taxes and other costs are not eligible under this program.
Applicant Eligibility
•
Must live within Greensboro city limits;
•
Household income is less than 80% Area Median Income; and
•
Be a U.S. citizen or legally admitted for residence in the United States. For the purposes of
this program, “r
esidency” is defined as a US citizen, permanent resident, resident with
eligible immigra
tion status, or have Deferred Action for Childhood Arrival (DACA) status.
This program is supported by Community Development Block Grant Coronavirus (CDBG-CV)
funds from the U.S. Department of Housing and Urban Development (HUD). Federal
regulations require that we obtain certain information to document that assistance is being
provided to low- and moderate-income households. Household income verification is
MANDATORY for program participation.
Confidentiality
All information provided on this form will remain confidential and will be available only to those
who need to confirm eligibility for assistance and to those who process the assistance to be
provided. This includes providing a copy of this application to the applicant's leaser, if requested.
Required Attachments
1.
Proof of Residency [i.e. driver's license or other governmental documentation evidencing
residency]
2.
Copy of Rent Statement or Lease Agreement and/or Utility Bill showing past due amount
3.
Household Income Verification with Proof of Financial Hardship [ex. paystubs, letter of
termination or furlough, proof of unemployment]
2
GENERAL INFORMATION
Please complete all information to be considered for assistance
Full Name:
Email Address:
Street Address:
Unit #:
City:
State:
Mobile Phone:
Other Phone:
Type of Dwelling:
Single-Family
Condo/Townhouse
Other Specify: ___________________________________
Annual Household Income:
Number of Persons in
Household:
Amount of Monthly Housing
Payment:
ASSISTANCE INFORMATION
Duplication of Benefits: Have you received assistance or received a commitment for assistance
related to COVID-19
from any other source?
Yes
No
If yes, please list
the agency:
If yes, be aware that you are not eligible to receive duplicate funding under this program.
Please detail any financial assistance you receive or will receive from other sources:
Provider
Description of Assistance
Amount Received
$
$
$
Identify the assistance you are requesting with this application. (Select all that apply.)
Rental Assistance
Water Utility Assistance
Electric Utility Assistance
Gas Utility Assistance
$
3
agency
agency:
Rental Information:
Grants will be payable to the rental agency
Name of rental
Website address:
Telephone:
Water Utility Information:
Grants will be payable to the utility provider
Name of Utility Provider
Website address:
Telephone:
Account #:
Electric Utility Information: Grants will be payable to the utility provider
Name of Utility Provider
Website address:
Telephone:
Account #:
Gas Utility Information:
Grants will be payable to the utility provider
Name of Utility Provider
Website address:
Telephone:
Account #:
4
CERTIFICATIONS
I certify the dwelling is my primary
residence:
Yes
No
I certify that I am one of the following:
a US citizen, permanent resident, have eligible
immigration status or have Deferred Action for
Childhood Arrival (DACA) status).
Yes
No
I agree to provide an additional statement
verifying my citizenship/residency status:
Yes
No
DECLARATION
By signing this application, I verify that all the information presented herein is true and correct to the
best of my knowledge. I agree that the rental agency listed above may be contacted to verify
information contained in this application. I provided all supplemental documents as required.
By signing this application I also acknowledge that evidence of eligible immigration status may be
released by the agency or the City without responsibility for the further use or transmission of the
evidence by HUD and the INS for the purposes of verifying individual immigration status.
Print Name of
Applicant:
Signature of
Applicant:
Date:
Mail, email, or fax application with attachments to the attention of:
Greensboro Housing Coalition
Attn: COVID-19 Relief
1031 Summit Ave, Suite 1E-2
Greensboro NC 27405
Email: GSOCovid19Relief@gsohc.org
Phone: 336.691.9521
For GHC Admin Use Only:
We have reviewed the attached City of Greensboro COVID-19 relief funding application and
recommend to GHC Accounting staff that it be considered for funding.
Recommended Amount:
$
Signature of Designated Staffer
(DS):
Special Notes:
For GHC Accounting Office Use Only:
Date Received from
DS:
Reviewed by:
Amount Approved/Processed for
Grant Funding:
$
Special Notes:
Rent $________ Water $_____
Electric $______ Gas $______
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City of Greensboro
Community Development Block Grant (CDBG) Rental/Utility Assistance Program
FY 2019-2020, Income Self-Certification for Program Applicants
This program is supported by Community Development Block Grant (CDBG) funds from the U.S. Department
of Housing and Urban Development (HUD). Federal regulations require that we obtain the following information
to document that assistance is being provided to low- and moderate-income households. This information is
collected for statistical purposes only and is kept in strict confidence. The applicant should complete this form
indicating all persons residing within their household, regardless of whether or not they are related. Income
verification is MANDATORY for program participation.
Applicant Name
Address
City & State Zip Code
1.
Status (Select all that apply): 62 years or older Disabled Male Female
2.
Is anyone in your household a Veteran? Yes
No
3.
Head of Household: Are you the head of household? Yes No
4.
If you are not the head of household, is the head of household female? Yes No
INCOME is defined as the total annual gross income of all family and non-family members 18+ years old
living within the household. All sources of income must be counted from all persons in the household based on
anticipated income expected within the next 12 months.
5.
Please circle your household size (Column A) on the chart below. Then, check your annual
household income range (Column B.) based on your household size:
A. Household
Size
B. Total Household Income
0-30%
31-50%
51-80%
1
❑
0 - $13,900
❑
$13,901 - $23,150
❑
$23,151 - $37,050
2
❑
0 - $17,240
❑
$23,151 - $26,450
❑
$37,051- $42,350
3
❑
0 - $21,720
❑
$26,451 - $29,750
❑
$42,351 - $47,650
4
❑
0 - $26,200
❑
$29,751 - $33,050
❑
$47,651 - $52,900
5
❑
0 - $30,680
❑
$33,051 - $35,700
❑
$52,901 - $57,150
6
❑
0 - $35,160
❑
$35,701 - $38,350
❑
$57,151 - $61,400
7
❑
0 - $39,640
❑
$38,351 - $41,000
❑
$61,401 - $65,600
8
❑
0 - $43,650
❑
$41,001 - $43,650
❑
$65,601 - $69,850
My annual household income is above the amounts listed on the table.
My total household income is
__________________________________________________
__________________________________________________
________________________
_________
6.
Please enter annual income for each household member 18 years of age and older.
ANTICIPATED ANNUAL HOUSEHOLD INCOME
Full Name
Wages/Salary
Benefits/Pension
Public
Assistance
Other Income
Source income documents are required to determine household eligibility for the program. These
documents may include: Prior year tax return, copies of wages statements, copy of Medicaid card, etc.
7.
Hispanic Ethnicity? Yes No
If either “Yes” or “No” is select above, you must also select a race below.
8. Race (Must check only one):
❑
White
❑
Black/African American
❑ Black/African American & White
❑ American Indian/Alaskan Native ❑ Asian
❑ Native Hawaiian/Pacific Islander ❑ Asian
& White
❑ American Indian/Alaskan Native & White
❑ American Indian/Alaskan Native & Black/African American
❑ Other/Multi-Racial:____________________
9. Please list anyone in your household that is living in your household. This may be adults or
children. Only list household members.
ADULTS OR CHILDREN LIVING IN THE HOUSEHOLD
Full Name
Age
Gender
Hispanic
(Y/N)
Race
Applicant Certification:
I certify that the information provided on this form is accurate and complete, and that I am a resident of the City
of Greensboro. I further acknowledge that eligibility for services funded through the CDBG program is based
upon having a qualifying annual family income level, and that the income level and/or status I have indicated in
this self-certification is subject to further verification by the agency providing services, the City of Greensboro
and/or HUD. The information provided on this form is subject to verification by HUD at any time, and
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be
terminated for knowingly and willingly making a false or fraudulent statement to a department of the
United States Government.
I therefore authorize such certification and will provide documentation of all income sources upon request.
Applicant’s Signature: ____________________________________ Date: _________
GHC Staff Name (please print):_____________________________
Date:__________
GHC Staff Signature: _____________________________________
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Application for COVID-19 RentalUtility Assistance City of Greensboro

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Completed 3 February 2021

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