Fillable CITY OF LOS ANGELES EMERGENCY RENTERS ASSISTANCE SUBSIDY

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CITY OF LOS ANGELES EMERGENCY RENTERS ASSISTANCE SUBSIDY

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CITY OF LOS ANGELES
EMERGENCY RENTERS ASSISTANCE SUBSIDY PROGRAM
Program Participation – Tenant Agreement
Applicant Tenant:
Tenant Address:
TO BE COMPLETED BY THE TENANT
LANDLORD/LEGAL OWNER’S NAME (PLEASE PRINT):
MAILING ADDRESS:
EMAIL ADDRESS:
PHONE NUMBER:
I am applying for the City of Los Angeles Emergency Renters Assistance Subsidy Program. This Program can
provide up to $1,000 towards monthly rent for up to a maximum of $2000 per unit. The Housing Rights Center
will not be responsible for any rent not described in this agreement, late fees or any other related fees or cost.
This assistance may be terminated if neither I nor the Landlord am no longer eligible, was never eligible or for
failure to submit all required documents which include the following:
An applicant must provide:
Photo Identification & Los Angeles Residence:
· California Driver’s License/ID or other U.S. state-issued License/ID (current or within one year of past
expiration) or
· U.S. Passport or Government/Consulate issued ID with address (current or within one year of past
expiration) or
· U.S. Military ID with address (current)
· Permanent Resident Card with address (current)
· Visa with address (current)
Proof of Tenancy
with Current Applicant Address (at least one document):
· Residential Rental or Lease Agreement; or
· A notice provided by the current landlord with the landlord’s name, address, phone number or email;
· Bank statement; or
· Utility bill (water, electric, gas, landline telephone – no cell phone, internet, etc.) issued in March 2020
or later; or
· A USPS postmarked letter from a government or official agency
2019 Household Income (at least one per working adult in the household)
· 2019 Tax Return; or
· 2019 W-2 for all wage earners; or
· 2019 1099 for all wage earners; or
·
Pay Stubs for all wage-earners; or
Rev 8.17.20
· Employer statement with contact information: Name, address, phone, dates of employment & income
earned; or
· Public Benefit Notice:
o CalWORKS or CalFRESH/SNAP; or
o General Relief;
o Medi-Cal;
o SSI/SSDI; or
o Veterans Benefits
Loss or Reduction of Income Due to COVID-19 (at least one)
· Layoff, Work Furlough or Reduction letter from employer; or
· Pay stubs or bank statements; or
· Medical expenses related to COVID-19; or
· Letter from childcare or adult services provider if service was discontinued; or
· Employer statement with contact information: Name, address, phone, dates of employment & income
earned; or
· Denial letter for:
o Unemployment Insurance; or
o SSI/SSDI; or
o Other public benefits
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. The landlord/legal owner does not live with me
in the same rental unit. I know that I am only eligible to receive a maximum of $2000 per unit in rental assistance
payments which will be paid directly to my Landlord. I know that I may be responsible for any remaining rent owed. I
understand that neither 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 may be held liable, 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:
Rev 8.17.20
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CITY OF LOS ANGELES EMERGENCY RENTERS ASSISTANCE SUBSIDY

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Completed 12 November 2020

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