Fillable BP City Of Fort Wayne Emergency Rental Assistance Program Application FINAL

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BP City Of Fort Wayne Emergency Rental Assistance Program Application FINAL

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City of Fort Wayne Emergency Rental Assistance Program Application 1 | Page
City of Fort Wayne Emergency Rental Assistance Program Application
Please complete this application in its entirety and have all required documentation prior to
submittal. The last page of this application contains a checklist of required documentation. For
questions or support, please reach out to the community partner you received this application from
or contact:
PHONE: 317-552-1463 E-mail: rent@cityoffortwayne.org
Paper applications should be returned to the community partner that you received the
application from or rent@cityoffortwayne.org.
Applicant Contact Information:
Applicant Name:_________________________________________________
Applicant Mailing Address: _________________________________________
City:__________________ State:_________ Zip Code:___________________
Phone number (required):________________ E-mail Address:___________________________
Required documentation: You must submit one of the following types of documentation:
Driver’s license or other state-issued ID
Legal permanent resident card (Green
card)
U.S. or foreign passport
Current foreign government issued ID
U.S. visa
Office of Refugee Resettlement ID
Work permit
Military ID
Matrícula consular
Social security card
Return application to Brightpoint
Email: gethelp@mybrightpoint.org
Fax: 260-420-8067
Phone: 1-800-589-3506 and
follow the prompts for
Emergency Rental Assistance
City of Fort Wayne Emergency Rental Assistance Program Application 2 | Page
Applicant Eligibility Questions:
1. Do you meet all of the eligibility criteria listed below: ________Yes ________No
a. I am a resident of the City of Fort Wayne, IN
b. I am at risk of homelessness or experiencing housing instability
c. I, or a member of my household, have qualified for unemployment or have
experienced a reduction in household income, incurred significant costs, or
experienced a financial hardship due to COVID-19
2. Enter the complete address for the residence for which you are applying for rent and/or
utility assistance. To be eligible for assistance you must be currently occupying the rental
unit.
Rental Unit Address: _____________________________________________
City:__________________ State:_________ Zip Code:___________________
Required documentation: Attach a copy of an executed lease agreement in the applicant’s
name, valid during the timeframe for which you are applying for assistance. If you do not
have a lease agreement in the applicant’s name, you must submit one of the following
documents in addition to the Landlord Attestation Form.
• Photo id with address of rental unit
• Current (within 60 days) utility bill listing name of applicant and address of rental
unit
• Mail from a government office, financial institution or utility provider listing
name of applicant and address of rental unit
3. Did you have past due rent payments prior to March 13th, 2020? This will not disqualify you
from receiving assistance as part of this program.
________Yes ________No
4. Did you have past due utility payments prior to March 13th, 2020? Note: this will not
disqualify you from being eligible for this program.
________Yes ________No
5. What is the gross household monthly or annual income? This must include income for all
adult household members.
$________________Gross household annual income OR
$________________Gross monthly household income
City of Fort Wayne Emergency Rental Assistance Program Application 3 | Page
Required documentation:
You do not need to submit ALL of the documents listed below. You should submit
any documents that are issued to you and/or members of your household which
document your household income.
Proof of Annual Income
• 2020 tax return listing all adult household members
• 2020 W-2(s) for every job held by each adult household member
• 2020 1099(s) for every job held by each adult household member
• 2020 1099G unemployment compensation statement
Proof of Monthly Income
• Monthly unemployment compensation statement for the two months prior to
application
• Pay stubs for the two months prior to application
• Most recent stipend(s), alimony, child support, pension/retirement/annuity monthly
award letter(s)
• Letter from employer verifying salary/wages for the two months prior to application
• Most recent SSI or SSDI statement of benefits
6. Have you or someone within the household been unemployed for at least 90 days prior to
the date of application submittal?
________Yes ________No
7. I, or a member of my household, have qualified for unemployment or have experienced a
reduction in household income, incurred significant costs, or experienced a financial
hardship due to COVID-19.
________Yes ________No
Required documentation: One of the following documents must be included as part of
your application. You may have already included one of these documents in response to
another question, in which case, you do not need to submit an additional document from
this list.
• Most recent unemployment statement
• Discharge, layoff, or furlough letter
• Pay stubs showing reduction in work
hours
• Pay stubs showing reduction in
income
• Notice of business closure (letter from
employer of closure, closure
announcement in newspaper, etc.)
• Documentation of significant costs
incurred, such as child or dependent
care or medical expenses
City of Fort Wayne Emergency Rental Assistance Program Application 4 | Page
8. What is the total number of adults (18 years or older) living in the household?: __________
9. What is the total number of minors (younger than 18 years) living in the household?: ______
10. Enter the total monthly rent payment you are responsible for making to your landlord.
DO NOT include any rental assistance you receive from federal, state or local assistance
programs that reduces the amount of rent you are responsible for.
Monthly Rent Payment: $_____________
11. Do you certify that the total monthly rent amount entered above is the tenant-owed (the
amount you pay) portion of your rent and does not include any federal, state or local rental
assistance?
________Yes ________No
12. Are you applying for assistance with past due rent payments? ________Yes ________No
Required documentation: Copy of rent statement showing past due amount and monthly
rental amount. Should be on letterhead of landlord/property manager. If a rent statement is
not available, the Landlord Attestation Form must be completed by the landlord and include
the past due rent amount.
13. Are you applying for assistance with future rent payments? ________Yes ________No
Required documentation: Landlord Attestation Form signed by the landlord and showing
future rent amounts OR executed lease agreement showing agreed upon rent amount for the
current lease.
14. Complete the table below for all utilities for which you are seeking assistance. Note, you
must attach past due utility bills showing amounts due after March 13
th
, 2020:
Utility
Utility Provider (i.e. AEP,
NIPSCO, City of Fort Wayne
Utilities)
Is this payment included in
the rent you pay to your
landlord (Yes/No)?
Electric
Gas
Water
Sewer/wastewater
Trash/refuse
City of Fort Wayne Emergency Rental Assistance Program Application 5 | Page
Required documentation: Statement of past due payments from the utility company, listed
by month. If possible, obtain a statement from your utility provider that shows monthly and
total past due amounts owed after March 13th, 2020.
15. Are you on a payment plan with the City of Fort Wayne Utilities? Note this does not make
you ineligible for assistance.
________Yes ________No
Applicant Demographic Questions:
Note the following questions are required for collection per the U.S. Department of Treasury but
have no impact on the applicant’s eligibility for assistance.
16. Select one of the following for applicant’s gender:
Male
Female
17. Select one of the following for applicant’s race:
White
Black/ African American
Asian
American Indian / Alaskan Native
Native Hawaiian / Other Pacific Islander
American Indian / Alaska Native & White
Asian & White
Black / African American & White
American Indian / Alaskan Native and Black / African American
Other Multi-Racial
18. Are you of Hispanic, Latino or Spanish origin?: ________Yes ________No
City of Fort Wayne Emergency Rental Assistance Program Application 6 | Page
Applicant agreement to program terms and conditions:
Read the terms and conditions in their entirety below and then indicate your acceptance by signing
and dating your application.
Emergency Rental Assistance Program Terms and Conditions
1. Consent to share information
a. I have requested assistance under the City of Fort Wayne Emergency Rental
Assistance Program. I authorize representatives from the City of Fort Wayne to supply and
receive all information I provide related to this Emergency Rental Assistance Program. I
understand and consent to the disclosure of public and non-public personal
information relating in any manner to my grant application or the award or servicing of any
grant by the City of Fort Wayne in connection with this Emergency Rental Assistance
Program, including, but not limited to: data and documentation verification, review, program
assistance evaluation, monitoring and oversight.
2. All information provided is truthful and accurate
a. I certify that I am legally authorized to submit this Application and the information
and statements that I have provided are truthful and accurate. I understand the information
and documentation submitted will be provided to a governmental agency and is subject to the
guidelines of the Consolidated Appropriations Act program and this Emergency Rental
Assistance Program. I agree to comply with the City of Fort Wayne Emergency Rental
Assistance Program guidelines. Failure to provide truthful and accurate information may cause
this application to be rejected.
3. Privacy Notice
a. We are asking that you provide the information requested on the Emergency Rental
Assistance Program application form to determine if you are eligible to participate in
the program. Personal information that you provide to the Emergency Rental
Assistance program about you may be considered public or personal information under
Indiana’s Public Access Laws. We will use your personal information only when it is required
for administration and management of the program. Persons or agencies with whom
this personal information may be shared include but are not limited to:
• Staff and other persons involved in program administration.
• Auditors who perform required audits of this program.
• Authorized personnel from local, state and federal agencies providing oversight
• Those persons who you authorize to see your personal information.
• Law enforcement personnel in the case of suspected fraud or
misrepresentation or other enforcement authorities as required.
Except as otherwise provided herein, we cannot release your personal information to
anyone else or use your personal information in any other way unless you give us
permission by completing a consent form that we will provide. Please keep in mind,
however, that your personal information must be released if required by court order, and,
in addition, your personal information may be released if Congress or
the Indiana Legislature enacts new legislation that authorizes or requires the release
of such information. 
City of Fort Wayne Emergency Rental Assistance Program Application 7 | Page
Entire Agreement
This Agreement, together with the City of Fort Wayne Emergency Rental Assistance Program Guidelines, City
of Fort Wayne Emergency Rental Assistance Program- Application, represents the final, complete, and
exclusive agreement between the Awardee and the City, and supersedes any and all prior written and
oral agreements, communications, or course of dealing between the Awardee and the City relating to
its subject matter.
Third Party Beneficiaries
This Agreement is for the exclusive benefit of the Awardee and the City, and not for the benefit of
any third party.
Expenditure of Funds
This assistance award is made for the purpose outlined in the City of Fort Wayne Emergency Rental
Assistance Program Guidelines and City of Fort Wayne Emergency Rental Assistance Program- Application and
may not be expended for any other purpose without the City’s prior written approval. Where at all
possible, payment of funds will be made directly to the landlord and/or utility provider of the
awardee for application to the awardees account with the landlord and/or utility provider.
Any portion of the assistance award found to be used for a purpose other than those outlined in
the City of Fort Wayne Emergency Rental Assistance Program Guidelines and City of Fort Wayne Emergency
Rental Assistance Program– Application must be paid back to the City immediately.
No Assignment or Delegation
You may not assign, or otherwise transfer, your rights or delegate any of your obligations under this
assistance award without prior written approval from the City.
Required Notification
You are required to provide the City with immediate written notification of: (1) any changes in your
household size, income or other factors which would affect eligibility of inclusion in the program;
(2) your inability to expend the assistance award for the purposes described in the City of Fort Wayne
Emergency Rental Assistance Program Guidelines; or (3) any expenditure from this assistance award made
for any purpose other than those for which the assistance award was intended.
Costs claimed under other programs
You may not claim costs under this program that have been previously reimbursed or claimed for
reimbursement under another Federal, State, or City financial assistance or disaster relief program.
City of Fort Wayne Emergency Rental Assistance Program Application 8 | Page
Right to Modify or Revoke
The City reserves the right to discontinue, modify or withhold any payments to be made under
this assistance award or to require a total or partial refund of any assistance award funds if, in the
City's sole discretion, such action is necessary: (1) because you have not fully complied with the
terms and conditions of this assistance award; (2) to protect the purpose and objectives of the
assistance award or any other activities of the City in their compliance with section H.R. 133-899
of the Consolidated Appropriations Act; or (3) to comply with the requirements of any law or
regulation applicable to you, or the City, or this assistance award program.
Applicant signature:_____________________________
Applicant printed name:__________________________
Date: ______________
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City of Fort Wayne Emergency Rental Assistance Program Application 9 | Page
Required documents checklist:
You do not need to submit this checklist with your application, it is for informational purposes only.
A complete application package contains:
Signed program application
Landlord Attestation Form
Proof of identity
Executed lease agreement or proof of residency at rental unit
Documentation of monthly or annual income
Documentation of financial hardship
Documentation of past due rent and/or utility payments
C
ITY OF FORT WAYNE LANDLORD EMERGENCY RENTAL
ASSISTANCE PROGRAM
LANDLORD/TENANT FORM & ATTESTATION
Prior to submission, with your application, make sure the following are complete:
1. Section A is complete and accurate.
2. Option 1, Option 2 or Option 3 are complete and accurate in Section
B.
3. The landlord has attached a completed and signed W-9 or has
indicated prior submittal.
S
ECTION A – LANDLORD AND TENANT INFORMATION
Landlord or Landlord’s Agent: _______________________
(“Landlord”) Phone number: Email:
Mailing Address:
City: State: Zip Code:
1.
Tenant. Tenant and/or landlord is seeking rental assistance for the following tenant’s household
(“Tenant”): First Name: Last Name:
Phone number: Email:
Mailing Address:
City: State: Zip Code:
2.
Unit. Tenant rents and currently occupies a rental unit (“Tenant’s Unit”) from Landlord located at:
Rental Address: Unit #
City: State: Zip Code:
3.
Rent. Tenant has agreed to pay Landlord $ per month in rent. This is the tenant paid portion
of the rent and does NOT include rental subsidies received by the tenant/landlord from federal, state
or local assistance programs such as housing choice voucher, project based rental assistance or public
housing)
4.
Past Due Rent. Tenant owes Landlord the following past due rent, including utilities paid
directly to Landlord, from March 13, 2020 through the application date: $ .
(Late fees are permitted only if legal and included in an existing lease.)
5.
Future Rent. Tenant’s unpaid rent due for the next three months after application submission:
Note: this should be future rent due to the landlord that is not yet past due. Total past due
rent should be included in question 4.
Month and Year ___ Rent due $
Month and Year ___ Rent due $
Month and Year ___ Rent due $
6.
Application of Funds. Landlord understands payment must be applied to the rent (including
any utilities and late fees) noted in this application. Landlord understands that Tenant may apply
for additional rent payments in 2021, up to three months at a time dependent upon fund
availability and program guidelines.
7.
No Other Governmental Rental Assistance. The above rent amounts have not been and
will not be paid by any other governmental rental assistance.
8.
No Rent Increase or Eviction for Nonpayment. Landlord agrees not to take any action
to evict Tenant for nonpayment of rent or any related costs for the months they are paid from
this program.
9.
Notification to Tenant. Landlord will provide Tenant with a copy of this form for submittal with the
tenant’s application.
10.
W-9. Landlord: submitted a W-9 to rent@cityoffortwayne.org; or
previously submitted a W-9 in connection with this program to
rent@cityoffortwayne.org
11.
Multiple tenants. Do you have other tenants who have applied or that you expect to
apply as part of this program?
______Yes _______No
12.
Please indicate if you would like to receive rent payments on behalf of the Tenant by
direct deposit. Please note this option is only available to landlords with multiple tenants:
______Yes _______No
SECTION B – LANDLORD/TENANT ATTESTATION
OPTION A: PARTICIPATING LANDLORD ATTESTATION AND SIGNATURE
COMPLETE THIS SECTION IF YOU AGREE TO PARTICIPATE IN THE
PROGRAM
By checking this box I agree to participate in the Emergency Rental Assistance
program as outlined above and accept payment for rent owed by the tenant listed on
this form
I certify, attest, and affirm under penalty of perjury that the above information is complete and
accurate to the best of my knowledge and belief. I authorize the US Department of Treasury and
the City of Fort Wayne to verify and investigate such information with my full cooperation at any
time. I understand that providing false or misleading statements or omissions to the United States
Government and the City of Fort Wayne, on this Form and Attestation may result in federal and
state criminal and civil actions for fines, penalties, damages or imprisonment.
I have read and understand the above attestation. Landlord is signing this Form & Attestation by
electronically completing the information below or by providing a wet signature.
Signature of landlord or authorized representative of property management/rental company:
_____________________________________________________
Printed Name:__________________________________________
Entity Name and Title (if applicable):________________________
Date: __________________________________
OPTION B: NON -PARTICIPATING LANDLORD ATTESTATION AND
SIGNATURE
COMPLETE THIS SECTION IF YOU DO NOT AGREE TO PARTICIPATE IN THE
PROGRAM
I do not agree to participate in this program and understand that payment will be made
directly to the tenant.
Landlord is signing this Form & Attestation by electronically completing the information
below or by providing a wet signature.
Signature of landlord or authorized representative of property management/rental company:
_____________________________________________________
Printed Name:__________________________________________
Entity Name and Title (if applicable):________________________
Date: __________________________________
OPTION C: TENANT ATTESTATION OF LANDLORD NON-PARTICIPATION
FOR TENANT USE ONLY IF LANDLORD WILL NOT COMPLETE ANY PORTION
OF THIS FORM.
By signing below, I certify that I have made multiple attempts to have my landlord complete
and sign this form indicating their participation in this program and willingness to accept
payment. If payment is made directly to me, as the tenant, I will use the assistance award to
pay my landlord for the entire amount of past due or future rent applied for as part of this
program. I understand that the City of Fort Wayne or an agent acting on their behalf will also
attempt to contact my landlord for participation in the program, and if obtained, payment will
be made directly to my landlord on my behalf.
Tenant is signing this Form & Attestation by electronically completing the information below
or by providing a wet signature.
Signature of tenant/applicant applying for rental assistance funds:
_____________________________________________________
Printed Name:__________________________________________
Entity Name and Title (if applicable):________________________
Date: __________________________________
This form is required to be completed and returned with the tenant’s application for rental
assistance. More information about the program, as well as the link to the online application
are available at:
http://www.fwcares.org
For questions please contact
Email: rent@cityoffortwayne.org
Phone: 317-552-1463
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BP City Of Fort Wayne Emergency Rental Assistance Program Application FINAL

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Completed 31 January 2022

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