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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Tenant Self-Cert Income Loss 9.29.20
TENANT(S) CERTIFICATION
CITY OF LOS ANGELES EMERGENCY RENTERS ASSISTANCE SUBSIDY PROGRAM
Tenant(s) COVID-19 Economic Loss Certification
Tenant Applicant:
Tenant Address:
Tenant Phone: Tenant Email:
INSTRUCTIONS: This is a written statement documenting and certifying that the Tenant Applicant’s household experienced financial
hardship as a result of the COVID-19 pandemic. Please check all that apply to describe how the Tenant household's income has been
reduced from March 13, 2020 to the present (e.g., lost employment or reduced income, either temporarily or permanently).
Employment loss, workplace closure or reduced hours resulting from economic impacts of COVID-19:
•
What is the name of the employer(s) or business if self-employed?
•
What is the email address and/or contact number of the employer(s)?: _
_
Did you or a household member become unemployed after March 13, 2020 as a result of the COVID-19 pandemic? ☐ Yes ☐ No
•
What was the date of business closure or your separation from your employer(s)?
Have your or other household members’ work hours or wages been reduced as a result of the COVID-19 pandemic? ☐ Yes ☐ No
Please retain your documentation for at least one year in case it is requested by this Program at a later time.
Other economic impact may be shown by the following events. Please mark or check all that apply or add your other reason(s):
Suspected or confirmed case of COVID-19 or caring for a household or family member who has a suspected or confirmed case.
Substantial out-of-pocket expenses for child care needs, medical expenses, or health care expenditures related to diagnosis and
testing for and/or treatment of COVID-19 of the tenant or household member.
Loss of ability to work due to COVID-19 related school closure or remote instruction of children in the household, or loss of child-
care or adult care due to school closure, remote operations, nursing home or adult daycare closure related to COVID-19.
Compliance with a recommendation from a government health authority to stay home, self-quarantine, or avoid congregating
with others during the state of emergency.
Any additional factors relevant to the tenant household reduction in income as a result of the COVID-19 emergency:
By signing below, I understand that making a false statement or providing false information is subject to civil and criminal
penalties under the laws of the State of California and the laws of the United States. Criminal charges may include but are
not limited to: perjury, grand theft, filing false documents with a public office, and obtaining money under false pretenses.
The Tenant Applicant certifies and signs under penalty of perjury under the laws of the state of California that the household
experienced an economic loss related to the COVID-19 pandemic and that the information provided for the household is
complete, true and correct.
Signature Printed Name Date
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Tenant Self-Cert Income Loss 9.29.20
TENANT(S) CERTIFICATION
CIUDAD DE LOS ANGELES PROGRAMA DE SUBSIDIO DE EMERGENCIA PARA ASISTENCIA DE ALQUILER
Inquilino(s) COVID-19 Certificación de Perdida Económica
Inquilino Solicitante:
Dirección del Inquilino:
Numero de Teléfono: Correo Electrónico:
INSTRUCCIONES: Esta es una declaración escrita documentado y certificando que el ingreso del inquilino solicitante experimento
dificultades financiaras como resultado de la pandemia del COVID-19. Por favor marque todas las que apliquen para describir como
el ingreso del hogar del inquilino ha sido reducido desde marzo 13 del 2020 hasta la fecha presente (ej. pérdida del empleo o reducción
del ingreso, de manera temporal o permanente).
Pedida del empleo, cierre del lugar de trabajo, reducción de horas como resultado del impacto económico del COVID-19:
•
¿Cuál es el nombre de su empleador (ores) o si trabaja por cuenta propia?
•
Cuál es el correo electrónico y/o el número de contacto de su empleador (ores)?: _
_
¿Usted o algún miembro de su familia quedaron desempleados despues del 13 de marzo del 2020 como resultado de la pandemia del
COVID-19?
☐ Si ☐ No
•
¿Cuándo fue la fecha del cierre del negocio o la terminación de su empleo(s)?
¿Ha tenido usted o un miembro del hogar reducción de horas o de salario como resultado de la pandemia del COVID-19? ☐Si ☐ No
Por favor guarde su documentación por lo menos un año en caso de que sea solicitada por este programa en el futuro.
Otros impactos económicos pueden ser señalados por los siguientes eventos. Por favor marque o señale todas las que aplican o indique
otra razón (es):
Caso sospechoso o confirmado por COVID-19 o cuidado de un miembro del hogar o un miembro de la familia que ha tenido un caso
sospechoso o confirmado.
Gastos sustanciales fuera del presupuesto debido al cuidado de menores, gastos médicos, o gastos de salud relacionados con
el diagnóstico y prueba de o tratamiento del COVID-19 del inquilino o de un miembro del hogar.
Perdida de la habilidad de trabajar debido al COVID-19 relacionado con el cierre de escuelas o instrucción remota para los
menores de la casa, o perdida de cuidado de menores o cuidado de adulto debido al cierre de las escuelas, operaciones
remotas, asilo de ancianos o cierre de hogares para la vejez relacionado con el COVID- 19.
Cumplimiento con las recomendaciones de la autoridad gubernamental de salud de quedarse en casa, auto-cuarentena, o el
evitar congregarse con otros durante la emergencia del estado.
Cualquier factor adicional relevante a la reducción del ingreso del hogar como resultado de la emergencia del COVID-19:
Al firmar aquí, yo entiendo que hacer una declaración falsa o proveer información falsa está sujeta a penalidades civiles y
criminales bajo las leyes del Estado de California y las leyes de Los Estados Unidos. Los cargos criminales pueden incluir
mas no están limitados a: perjurio, fraude, archivar documentos falsos con una oficina pública y obtener dinero bajo
pretensiones falsas.
El Inquilino Solicitante certifica y firma bajo pena de perjurio bajo las leyes del estado de California que los miembros del
hogar han experimentado perdidas económicas relacionados a la pandemia del COVID-19 y que la información proveída por
los miembros del hogar, es correcta y verdadera.
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CITY OF LOS ANGELES EMERGENCY RENTERS ASSISTANCE SUBSIDY

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Completed 11 November 2020

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