Fillable CITY OF LOS ANGELES 2021 COVID-19 EMERGENCY RENTERS (Microsoft)

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CITY OF LOS ANGELES 2021 COVID-19 EMERGENCY RENTERS (Microsoft)

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Rev 4.22.21
CITY OF LOS ANGELES
2021 COVID-19 EMERGENCY RENTERS ASSISTANCE PROGRAM (ERAP)
Tenant Participation Agreement
Applicant Tenant:
Tenant Current Rental Unit Address:
Tenant Mailing Address (If different than the physical address of the rental unit):
Tenant Email Address: Tenant Phone Number:
TO BE COMPLETED BY THE TENANT
Please complete the below information regarding your landlord. Your landlord is the
person that you pay your monthly rent to and/or is in charge of managing the property and
aware of your tenancy.
LANDLORD NAME (PLEASE PRINT):
PROPERTY MANAGEMENT COMPANY (if applicable):
LANDLORD MAILING ADDRESS:
EMAIL ADDRESS:
PHONE NUMBER:
I am applying for the City of Los Angeles Emergency Renters Assistance Program (ERAP). I understand that if my
application is approved and my landlord agrees to participate in the program, my landlord will receive 80% of my
unpaid rent and will waive the remaining 20% from my back rent owed from April 1, 2020, to March 31, 2021. If
my landlord does not wish to participate in the program, I may receive a direct payment of 25% of my back rent
owed from April 1, 2020, to March 31, 2021, plus 25% of three months' prospective rent. I understand that if I do
receive a direct payment, I must pay my landlord the financial assistance to be applied to my rent. These rules are
in alignment with regulations established by California Senate Bill 91. The City of Los Angeles and its partner
agency will not pay for any rent not described in this agreement, late fees, return check fees, or any other related
fees or cost. This assistance may be terminated if either I or my Landlord are found to be ineligible, or for failure
to submit all required documents within the required period which include the following:
An applicant must provide:
Proof of Identification
• Government issued Birth Certificate, Driver’s License or ID, Passport; or
• Government/Consulate Card, Permanent Resident Card or Visa; or
• Military or other Government Identification.
• Employment identification card; or
• Marriage license/certificate or certified divorced decree; or
• Current school records documenting a student’s status as full-time at a degree or certificate
granting institution (Only for household members 18 years and older).
Proof of Residential Tenancy
• Rental Agreement/Lease with applicant’s and landlord’s name and address; or
Rev 4.22.21
• A notice provided by the current landlord addressed to the tenant with the landlord’s name
and the landlord’s address, phone number, or email address; or
• A Bank statement with the applicant’s name and address; or
• A USPS postmarked letter from a government or official agency; or
• Receipt of previously paid rent provided by your landlord with applicant’s and landlord’s
name and address.
Proof of Current and Past Due Rent Amount
• Lease/Rental Agreement or an addendum to the lease agreement including a Notice of Rent
Increase that was signed on or after January 1, 2020; or
• Rent ledger, rent receipts from no earlier than March 1, 2020, or a Notice to Pay Rent or Quit
that lists the current monthly rent and the amount owed; or
• 3 or 15-Day Notice to Pay Rent or Quit; or
• Any document that states current and/or past due monthly rent.
Proof of Annual 2020 Household Income for All Household Members
• 2020 household tax returns (AGI), Form 8879, Interest income on 1099, or Net Profit on the
Schedule C; or if a household is not required to
complete a tax return, a Form W-2 for all
wage earners: Wages, tips, and other compensation or
other tax statements; or
• Unemployment statements or benefits letters (with name, amount of benefit, and dates of
coverage); or
• Social Security and Social Security Disability Insurance statements or benefits letters (with
name, amount of benefit, and dates of coverage); or
• Documentation of current participation in any one of the below (with name, amount of
benefit, and dates of coverage):
o Medicaid, known as Medi-Cal in California; or
o Women, Infants, and Children (WIC) benefits; or
o Free and Reduced Lunch participation; or
o Supplemental Nutrition Assistance Program (SNAP), known as CalFresh in California; or
o Food Distribution Program on Indian Reservations (FDPIR); or
o Temporary Assistance for Needy Families (TANF), known as CalWORKs in California; or
o School Nutrition Programs (SNP), such as the Free and Reduced Lunch program for
California families; or
o General Relief; or
o Veterans Benefits; or
o Any household income-based state or federally funded assistance program for low-
income persons or households; or
o Any locally operated assistance program for low-income persons or households that
requires household income verification and uses federal income limits
• I do not have any documentation to prove my annual 2020 household income. I will complete
a self-attestation form under penalty of perjury.
Proof of Monthly 2021 Household Income for All Household Members
• Employer statement with employee name, dates of employment, income earned, and the
employer’s name and the employer’s address, phone number, or email address; or
• Two recent consecutive pay stubs for all wage earners (use gross pay) (Non-consecutive pay
stubs is acceptable for entertainment, construction, or other like industries).
• I do not have any documentation to prove my monthly 2021 household income. I will
complete a self-attestation form under penalty of perjury.
Proof of Unemployment and/or Financial Hardship Due to COVID-19
• Unemployment benefits/insurance statement/letter showing household member’s name and
benefit amount; or
• Layoff, Work Furlough, or Reduction letter from employer (with employer name and at least
employer’s address, phone number, or email address) with employee name; or
Rev 4.22.21
• Letters of termination; or
• Two consecutive pay stubs (use gross pay) (Non-consecutive is acceptable for entertainment,
construction, rideshare, or other industries alike) or recent bank statements which must have
two itemized statements (no summaries or screenshots); or
• Last-received pay stub with employer’s information; or
• Evidence of application for unemployment benefits; or
• Evidence of expired unemployment benefits, including unemployment benefits provided
through the CARES Act; or
• Medical expenses related to COVID-19; or
•
A letter addressed to a household member from childcare or adult services provider if service
was discontinued; or
• Employer statement with employee name, dates of employment, income earned, and with
the employer’s name and the employer’s address, phone number, or email; or
• For self-employed persons, tax records, statements, or other documentation of loss of
income; or
• I do not have any documentation to prove my financial hardship due to COVID-19. I will
complete a self-attestation form under penalty of perjury.
LA City ERAP Tenant Participation Agreement
• Required: LA City ERAP Tenant Participation Agreement.
TENANT CERTIFICATION
I UNDERSTAND AND CERTIFY THAT: All of the information and supporting documentation that I have provided with this
application is accurate and correct to the best of my knowledge. I understand that neither the City of Los Angeles, the
Housing Rights Center, nor its affiliates are providing me with legal representation, counsel, or advice and will not represent
me in any legal action that might arise from this agreement or concerning my tenancy. I understand that by applying for this
program I am not guaranteed financial assistance as this program has limited funding. I may be held liable, prosecuted to the
fullest extent of the law, and have to repay this assistance and face legal penalties if I commit fraud or knowingly assist a
Landlord to commit fraud to receive this assistance.
THE TENANT MUST SIGN AND DATE:
I certify or declare under the penalty of perjury under the laws of the state of California that the foregoing is
correct and true.
TENANT NAME (PLEASE PRINT):
TENANT SIGNATURE:
DATE:
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CITY OF LOS ANGELES 2021 COVID-19 EMERGENCY RENTERS (Microsoft)

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Completed 18 May 2021

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