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CITY OF LOS ANGELES EMERGENCY RENTERS ASSISTANCE SUBSIDY

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Page 1
LA ERA TENANT HOUSEHOLD INCOME CERTIFICATION 9.29.20
CITY OF LOS ANGELES EMERGENCY RENTERS ASSISTANCE SUBSIDY PROGRAM
Tenant Annual Household Income Self-Certification
Tenant Applicant Name:
Tenant Address:
Tenant Phone: Tenant Email:
TENANT ANNUAL HOUSEHOLD INCOME Prior to March 13, 2020
TENANT(S) HOUSEHOLD MEMBERS INCOME INFORMATION - To complete this form, fill in ALL INCOME EARNINGS for EACH TENANT
AND HOUSEHOLD MEMBER AGE 18 OR OLDER. Only report the annual income earned in 2019 or in 2020 as of March 13, 2020. The
purpose of this form is to help the tenant’s household calculate and report what the total household annual income was before March
13, 2020 (prior to COVID19 related income loss). There is also a row at the end of this list to report no income earned if applicable. Add
all of the income for each household member from each source of income together and insert that amount as the “Total Annual
Household Income.” The Tenant Applicant must then sign this statement on the behalf of the household to certify that the information
is complete and accurate, and that documentation of the source of income will be provided upon request.
SOURCE OF INCOME
(Indicate for each if income reported
was earned one time or weekly, bi-
monthly, monthly or annually.)
Household
Member (HM)
# 1
Household
Member
(HM)
# 2
Household
Member
(HM)
# 3
Household
Member
(HM)
# 4
Household
Member
(HM)
# 5
Household
Member
(HM)
# 6
Income from Employment
$
$
$
$
$
$
Name of Employer(s)
Type of Business/Job Title
Self-Employed Profits
$
$
$
$
$
$
Social Security
$
$
$
$
$
$
Supplemental Security Income (SSI)
$
$
$
$
$
$
Social Security Disability (SSD)
$
$
$
$
$
$
California Work Opportunity and
Responsibility for Kids (CalWORKs)
$
$
$
$
$
$
Pension
$
$
$
$
$
$
Alimony
$
$
$
$
$
$
Child Support
$
$
$
$
$
$
Page 2
LA ERA TENANT HOUSEHOLD INCOME CERTIFICATION 9.29.20
SOURCE OF INCOME
HM # 1
HM # 2
HM # 3
HM # 4
HM # 5
HM # 6
Unemployment Insurance
$
$
$
$
$
$
Interest from Bank Accounts/Cash
Funds
$
$
$
$
$
$
Other Income (Name Sources):
$
$
$
$
$
$
1. ADD ALL OF THE INCOME
AMOUNTS FOR EACH COLUMN. (
Ex.
HM1 Income: $800/week x 52 weeks =
$41,600/year + $8,000 child support
annually. Total is $49,600 for HM1)
$
$
$
$
$
$
2. TOTAL ANNUAL HOUSEHOLD INCOME. Add the total amounts for each HM (Household Member) from 1. together
to calculate the TOTAL ANNUAL HOUSEHOLD INCOME (HM#1 + HM#2 + HM#3 + HM#4 + HM#5 + HM#6) and insert
that amount here:
$
TENANT CERTIFICATION
By signing below, I understand that making a false statement or providing false information is subject to civil and criminal
penalties, including confinement and fines under the laws of the State of California and the United States.
I understand that if I am determined to be eligible for this program, I may be required to submit income documentation
to prove my eligibility at a later time. I acknowledge and understand that the City and HRC have provided no warranty or
guarantee as to award selection, and waive any responsibility and liability of the City and HRC, and all of its departments,
employees, and elected officials, from damages and losses caused by my non-selection and waive all errors and failures
occurring during the application processing and transmissions of rental payment.
TENANT APPLICANT IS OVER 18 YEARS OF AGE AND SIGNS UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE
OF CALIFORNIA THAT THE INFORMATION PROVIDED FOR ALL HOUSEHOLD MEMBERS IS COMPLETE, TRUE AND CORRECT.
Signature Printed Name Date
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Page 1
LA ERA TENANT HOUSEHOLD INCOME CERTIFICATION 9.29.20
CIUDAD DE LOS ANGELES PROGRAMA DE SUBSIDIO DE EMERGENCIA PARA
ASISTENCIA DE INQUILINOS
Auto Certificación del Ingreso Anual del Inquilino
Nombre del Inquilino Solicitante:
Dirección del Inquilino:
Teléfono del Inquilino: Correo Electrónico del Inquilino:
INGRESO ANUAL DEL HOGAR DEL INQUILINO antes del 13 de marzo del 2020
INQUILINO (S) INFORMACION DE INGRESOS DE LOS MIEMBROS DEL HOGAR – Para completar esta forma, llene TODO EL INGRESO
OBTENIDO POR CADA INQUILINO Y MIEMBDO DEL HOGAR DE 18 ANOS O MAYORES. Solamente reporte el ingreso anual obtenido en 2019
o 2020 hasta el 13 de marzo del 2020. El propósito de esta forma es para ayudar a el hogar del inquilino a calcular y reportar cuales fueron
todos los ingresos anuales antes del 13 de marzo del 2020 (antes de la perdida de ingreso relacionada al COVID-19). También hay una
columna al final de la lista para reportar no ingreso obtenido si fuera aplicable. Agregue todo el ingreso de cada miembro del hogar y de
cada fuente de ingreso junta e inserte la cantidad como un “ingreso total anual del hogar. “El inquilino solicitante debe de firmar la
declaración en representación del hogar y certificar que la información está completa y correcta, y que la documentación de la fuente de
ingreso será presentada una vez que sea solicitada.
FUENTE DE INGRESO
(Indique cada ingreso reportado
ganado una vez o semanal, quincenal,
mensual o anualmente)
Miembro del
Hogar (MH)
#1
Miembro
del Hogar
(MH)# 2
Miembro
del Hogar
(MH)# 3
Miembro
del Hogar
(MH)# 4
Miembro
del Hogar
(MH)# 5
Miembro
del Hogar
(MH)# 6
Ingreso por empleo
$
$
$
$
$
$
Nombre del empleador(s)
Tipo de Negocio/Titulo del Trabajo
Ganancias por empleo por Cuenta
Propia
$
$
$
$
$
$
Seguro Social
$
$
$
$
$
$
Ingreso del Seguro Suplemetal (SSI)
$
$
$
$
$
$
Seguro Social por Incapacidad (SSD)
$
$
$
$
$
$
Oportunidad de Trabajo en
California y Responsabilidad por
Menores (CalWORKs)
$
$
$
$
$
$
Pensión
$
$
$
$
$
$
Manutención Alimenticia
$
$
$
$
$
$
Page 2
LA ERA TENANT HOUSEHOLD INCOME CERTIFICATION 9.29.20
Manutención del Menor
$
$
$
$
$
$
FUENTE DE INGRESO
MH # 1 MH # 2 MH # 3 MH # 4 MH# 5
MH # 6
Seguro de Desempleo
$
$
$
$
$
$
Intereses de Cuenta de Banco/
Fondos en Efectivo
$
$
$
$
$
$
Otro Ingreso (Nombre de la Fuente):
$
$
$
$
$
$
1. Agregue TODOS LAS
CANTIDADES DE INGRESOS DE
CADA COLUMNA. (
Ej. MH1 ingreso:
$800/semanal x 52 semanas =
$41,600/año+ $8,000 manutención
al menor anualmente. Total es
$49,600 para MH)
$ $ $ $ $
$
2. INGRESO ANUAL TOTAL DEL HOGAR. Agregue las cantidades totales de cada MH (Miembro del Hogar de 1. Juntas
calcule el INGRESO ANNUAL TOTAL DEL HOGAR (MH#1 + MH#2 + MH#3 + MH#4 + MH#5 + MH#6) e inserte la cantidad
aquí:
$
CERTIFICACION DEL INQUILINO
Al firmar lo siguiente, yo entiendo que hacer una declaración falsa o proporcionar información falsa está sujeto a las
penalidades civiles y criminal incluyendo la confiscación y multas bajo las leyes del Estado de California y de los Estados
Unidos
Yo entiendo que, si yo fuera determinado para ser elegible para este programa, yo talvez seré requerido a proporcionar
documentación de ingresos para demostrar mi elegibilidad en cualquier momento. Yo reconozco y entiendo que la Ciudad
y HRC no garantizan o proporcionan garantía para ser escogido en la selección, y renuncio a cualquier obligación y
responsabilidad de la Ciudad y HRC, y todos los departamentos, empleados, y oficiales electos, de cualquier daño o perdida
causada porque yo no fui seleccionado y renuncio a cualquier error y fallas ocurridas durante el proceso de la aplicación y
la trasmisión del pago del alquiler.
El NQUILINO SOLICITANTE ES MAYOR DE 18 ANOS Y FIRMA BAJO PENA DE PERJURIO BAJO LAS LEYES DEL ESTADO DE
CALIFORNIA QUE LA INFORMACION PROPORCIONADA DE TODOS LOS MIEMBROS DEL HOGAR ES CORRECTA Y
VERDADERA.
Firma Nombre Escrito Fecha
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CITY OF LOS ANGELES EMERGENCY RENTERS ASSISTANCE SUBSIDY

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Completed 24 November 2020

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