PA 600 ERA 2/22
Application for Emergency Rental Assistance
Who’s applying? Tenant Landlord (on behalf of tenant)
Tenant Information
Last Name First Name SSN# (optional)
Address City Zip County
Phone Email Address Date
Household: Number of Adults ____________ Number of Children under 18 ____________
Has anyone in your household experienced nancial hardship which may include, but not limited to, a period of
unemployment, a decrease in household income or had increased household costs?
Yes No
If Yes, was this nancial hardship during or due, directly or indirectly, to COVID–19?
Yes No
Is anyone in your household at risk of homelessness or housing instability? Yes No
Has anyone in the household received federally funded rental assistance in the past 12 months? Yes No
If yes, did anyone receive Emergency Rental Assistance in Pennsylvania in the past 12 months? Yes No
If YES, STOP and complete an ERAP recertication.
Are you a veteran? Yes No Has anyone been a victim of domestic violence? Yes No
Citizenship (optional): US Citizen Permanent Resident Temporary Resident Refugee Other
Race (check all that apply): American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Pacic Islander White Other
Ethnicity: Hispanic Non-Hispanic Gender: Male Female
Landlord or Property Manager Information
Property Management Company (if applicable)
Last Name First Name Tax ID# or SSN#
Address City Zip
Phone Email Address
Tenant Utility Information
Company Name Address (Street, City, Zip) Phone Account #
PA 600 ERA 2/22
Tenant Household Income
Please tell us about the income of any individual in your household who is 18 or over.
Does anyone in your household have any income? Yes No
If yes, check all that apply, and list the income you have already received.
Guardian Fees
Money Earned from Babysitting
Money for Training
Money Paid to You for Loans
Money Paid to You for Rent
Money Paid to You for Room or Board
Sick Benets
Social Security
Supplemental Security Income (SSI)
Union Pay
Veteran Benet
Wages from Employment
Workers Compensation
Name of Person with Income Type/Source of Income/Name of Employer
How Much?
How Often
Date of Most
Recent Payment
Tenant Household Expenses
Other (explain below)
Provider ________________
Provider ________________
Provider ________________
Provider ________________
Provider ________________
Provider ________________
Provider ________________
Provider ________________
Provider ________________
Monthly $______________
Monthly $______________
Monthly $______________
Monthly $______________
Monthly $______________
Monthly $______________
Monthly $______________
Monthly $______________
Monthly $______________
Arrears $______________
Arrears $______________
Arrears $______________
Arrears $______________
Arrears $______________
Arrears $______________
Arrears $______________
Arrears $______________
Arrears $______________
PA 600 ERA 2/22
Rights and Responsibilities
This institution is prohibited from discriminating on the
basis of race, color, national origin, disability, age, sex
and in some cases religion or political beliefs.
Persons with disabilities who require alternative means
of communication for program information (e.g. Braille,
large print, audiotape, American Sign Language, etc.),
should contact the Agency (State or local) where they
applied for benefits. Additionally, program information
may be made available in languages other than English.
To file a complaint of discrimination, write to:
U.S. Department of the Treasury,
Director, Office of Civil Rights and Diversity,
1500 Pennsylvania Avenue, N.W.,
Washington, DC 20220;
call (202) 622-1160;
or send an e-mail to:
This institution is an equal opportunity provider.
We will keep your information private. It will only be
used to decide which programs you may be eligible
for. Any person knowingly violating any of the rules
and regulations of this department shall be guilty of a
misdemeanor and, upon conviction shall be sentenced to
pay a fine, not exceeding one hundred ($100) dollars, or
to undergo imprisonment, not exceeding six months, or
both (62 P.S. section 483).
You must give true, correct and complete information.
You must help in proving the information, you give.
Benefits may be denied if you fail to provide certain proof.
If you are contacted by Department of Human Services
(DHS) or the Office of State Inspector General, you must
fully cooperate with those persons or investigators.
The collection of this information, including the Social
Security number (SSN) of each household member, is
authorized under 42 U.S.C. § 405(c)(2)(C)(i-iv) and 62
P.S. § 432.2(b)(3).
The information will be used to determine whether
your household is eligible or continues to be eligible
to participate in the Emergency Rental Assistance
Program. We will verify this information through
computer matching programs. This information will
also be used to monitor compliance with program
regulations and for program management.
This information may be disclosed to other federal
and state agencies for official examination, and to law
enforcement officials for the purpose of apprehending
persons fleeing to avoid the law. Failure to provide
an SSN may result in the denial of Emergency Rental
Assistance to each individual failing to provide an SSN.
Any SSNs provided will be used and disclosed in the
same manner as SSNs of eligible household members.
If someone wants help getting an SSN:
(1) call: 1-800-772-1213 or 1-800-325-0778 (TTY); or
(2) visit:
You have the right to ask for a hearing to appeal a
decision if you believe it is unfair or incorrect, or if the
provider fails to act on your application for benefits.
You may file the appeal through the county agency
by following the information provided on the eligibility
determination notice from the ERAP agency for your
If you appeal, you may also request a conference with
the ERAP agency before the hearing.
At the hearing you may represent yourself, or someone
else, such as a lawyer, friend or relative may represent
PA 600 ERA 2/22
I understand and agree that I am responsible for any fraudulent statements made on this application, even if the
application is being submitted by someone acting on my behalf. I certify that all information that has been entered is
true under penalty of perjury. I understand that the information entered in this application will be kept condential and
used only to administer benets. I understand that I may be required to work with other agencies as a condition of my
approval for assistance. I agree to provide upon request any additional documentation required (i.e. pay stub, lease,
recent bills, proof of unemployment etc) to aid in determining eligibility.
Signature - Tenant
Name Printed - Tenant
Signature - Landlord (only if form was completed by landlord)
Name Printed - Landlord (only if form was completed by landlord)
Authorization for Release of Information (Tenant only)
I hereby authorize and request the disclosure to the county oce any information concerning the age, residence,
citizenship, employment, income, and any additional information involving eligibility for the rental and utility assistance
programs for myself. It is understood that the information obtained will only be used for determination of rental/utility
assistance or other housing assistance programs.
Signature of Tenant Date
Name Printed - Tenant
ERAP Agency Use Only
Authorization Information: Approved Denied Date:________________________
Type(s) of Assistance Provided:
Rental Assistance Rental Arrears Housing Stability Services Utility Assistance Utility Arrears
Amount of Assistance:
Rental Assistance $__________ Rental Arrears $__________ Housing Stability $__________ Other $__________
Utility Assistance $___________ Utility Arrears $___________ Total $____________________
Number of months covered with: Rental Assistance____ Rental Arrears____ Utility Assistance____ Utility Arrears____
Household Income Level:
Does not exceed 30 percent of the area median income for the household
Exceeds 30 percent but does not exceed 50 percent of the area median income for the household
Exceeds 50 percent but does not exceed 80 percent of area median income for the household
Notes: Used annual calculation for eligibility Used monthly income at time of application
Categorically Eligible Fact Specic Proxy Self-Attestation