Fillable COLORADO EMERGENCY RENTAL ASSISTANCE PROGRAM (ERAP) INCOME SELF-ATTESTATION (Microsoft)

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COLORADO EMERGENCY RENTAL ASSISTANCE PROGRAM (ERAP) INCOME SELF-ATTESTATION (Microsoft)

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  • 11 check-boxes
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1
COLORADO EMERGENCY RENTAL ASSISTANCE PROGRAM (ERAP)
INCOME SELF-ATTESTATION FORM
INSTRUCTIONS
This template allows for applicants to self-attest their income eligibility for the Colorado Emergency
Rental Assistance Program (ERAP). Please complete this form if in the previous three (3) months you
had income that you are not able to verify with documentation, such as pay stubs (ex: self-
employment, wages paid in cash, income from a closed business, etc.).
Carefully read each section and complete ONLY the applicable criteria sections for which you are
unable to provide the required supporting documentation.
NOTE: This is a fillable form, and you can click directly on the boxes within each applicable below to fill
in your information directly. Once you have filled out the applicable criteria sections you must sign the
certification at the end and upload a copy of your identification with this form.
The completed and signed certification can be printed and attached to your paper application or
uploaded with your online application at https://portal.neighborlysoftware.com/ERAP-
COLORADO/Participant
Per guidance from the US Treasury, Colorado ERAP may perform additional testing or review
processes to help minimize the potential for fraud. The use of self-attestations may delay the
processing of your application, require additional information from you, or result in limitations to
the amount of assistance available to you.
Acknowledgement:
❖ Form to be completed by each household member (over 18 years of age) that is verifying
undocumented income.
❖ Self-attestation of household income will require that the Applicant recertify income every
three months to receive future funding (as available).
❖ I understand that providing false, incomplete, or inaccurate information on application forms or
seeking assistance for months in which assistance has been or will be provided, may result in
termination of participation in the Program and possible criminal liability.
2
APPLICANT INFORMATION (REQUIRED)
Name
Name of Primary Applicant for
Rental Assistance
Application Case Number
Rental Unit Address
Address 2
City
State
Relationship to Primary
Applicant (“self” for your name)
Please select the following the option(s) that best describes how you receive income:
◻ Income, but lack proof of income documentation (including the following sources: full and/or
part-time employment, Veteran Administration (VA) Compensation, gross rental or lease
income, unemployment benefits, social security benefits, Wages from a closed business, etc.)
◻ Self-Employed
◻ Cash Income
◻ No Income (Zero Income)
Note: After the above selection, complete the applicable section that applies on one of the following
pages AND complete the ‘Certification’ section on the last page.
3
SELF-ATTESTATION FOR LACK OF INCOME DOCUMENTATION AND/OR CASH
INCOME
(Complete this section ONLY IF you receive income, but it is either cash or you cannot submit proof of
that income. Example: you cannot find your paystubs, you do not have your unemployment benefits
statement, etc. Proceed to the ‘Certification’ section on the last page after completion.
If this does not apply to you, do not complete.)
Attestation of Lack of Income Documentation
Please detail the circumstances that prevent you from providing the required supporting documents
necessary to complete an income eligibility review. (Note: Explanation is Required)
If you received income or wages, please declare the total amounts below:
Source of Income /Employer
Cash Income
Received
Amount Earned
in the Last
Month
Income
Annual gross income from all sources
If available, provide contact information for someone who can verify your cash income. For
example, you may provide contact information for the person who hires you, a caseworker or
another professional who knows you earn cash income.
Name
Phone Number
Email address
How does this person know that you earn cash income?
$ 0.00
Select
Select
Select
Select
4
SELF-ATTESTATION FOR ZERO INCOME
INCOME
(Complete this section ONLY IF you have had not received any income within the past three (3) months).
If you recently lost income, note the date of when you last received income and reason for loss of
income. Proceed to the ‘Certification’ section on the last page after completion.
If this does not apply to you, do not complete.)
☐
I certify that I have not received income from any of the following sources in the last three
(3) months:
a. Wages from employment (including commissions, tips, bonuses, fees, etc.).
b. Income from operation of a business, contract work, or “gig” work, including cash
payments.
c. Sales from self-employed resources (Avon, Mary Kay, Shaklee, etc.), including cash
payments.
d. Rental income from real or personal property.
e. Interest or dividends from assets.
f. Social Security payments, annuities, insurance policies, retirement funds, pensions, or
death benefits.
g. Unemployment or disability payments.
h. Public assistance payments.
i. Periodic allowances such as alimony, child support, or gifts received from persons not
living in my household.
j. Any other source of income not named above.
How have you paid your household expenses such as food, transportation, internet, cell phone, and
health care during the last three months without income? (Note: Explanation is Required)
I have stated during this verification process that I have no income at this time. I have not received
income since __________________. I do not expect to receive any income until __________________.
Reason for Loss of Income
5
SELF-ATTESTATION FOR SELF-EMPLOYMENT
(Complete this section ONLY IF you were self-employed / owned your own business. Proceed to the
‘Certification’ section on the last page after completion.
If this does not apply to you, do not complete.)
Business Name
Business Address
Date Business Opened
Type of Business
Have Operations Been Continuous?
☐ Yes
☐ No
Date Business Closed (if applicable)
Net Income for 2020 Tax Year
Net Income for 2021 Tax Year (to date)
Verification of Self-Employment Income
(Check all that apply and attach the
documents if available)
☐ Previous Year’s Tax Return (reflecting self-
employment income)
☐ Year-to-Date Profit & Loss Statement
☐ Other Supporting Documentation of Income
If the business is closed, how have you paid your household expenses such as food, transportation,
internet, cell phone, and health care during the last three months?
6
CERTIFICATION (REQUIRED)
I agree to provide additional information or documentation upon request to the ERAP administrator.
I understand that I am reporting my past and current income for the Colorado Emergency Rental
Assistance Program (ERAP) to establish my eligibility and the determination of the amount of
assistance needed. I declare under penalties of perjury that the foregoing representations of the
income for my household are true, correct, accurate, and complete in all respects.
I understand that providing false, incomplete, or inaccurate information on application forms or
seeking assistance for months in which assistance has been or will be provided, may result in
termination of participation in the Program and possible criminal liability.
Printed Name Household
Member Self-Attesting
Signature of Household
Member Self-Attesting
Date
*Reminder: You must also upload a copy of your identification with this form.
Primary Applicant is signing on behalf of the household member
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COLORADO EMERGENCY RENTAL ASSISTANCE PROGRAM (ERAP) INCOME SELF-ATTESTATION (Microsoft)

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Completed 20 October 2021

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