Fillable COVID-19 Emergency Rental Assistance

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COVID-19 Emergency Rental Assistance

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Application for Assistance
To apply using this paper application, please ll out the applicable sections and sign the application where
indicated. Mail or Fax your application as indicated on page 2 of the application.
How Much Assistance is Available?
Every household’s situation is dierent, so the amount of assistance you may receive will be specic to your needs.
You may request assistance back to March 13, 2020. Prior expenses are not eligible.
Eligible costs include: rent, manufactured home lot rent, rental of a manufactured home, utilities including electric,
gas, power, heat, water, sewer, bulk fuel, eviction costs, fees charged by your landlord, hotel costs if the hotel is
your residence, and other costs related to keeping you in your home.
If you are requesting rental assistance, make sure the amount you request will be accepted by your landlord. If they
challenge the amount, it can delay your application’s processing.
Costs that are not eligible include: homeowner costs, homeowner utilities, landlord-paid utilities, landlord-paid
property taxes, property insurance, phone, internet, renter insurance.
How can RentHelpMN help me?
Depending on your circumstances, RentHelpMN assistance may:
• Bring your delinquent rent or utility bill(s) current.
• Pay up to 3 months of future rent at a time, until funds run out.
What happens next?
If you qualify for rent assistance, we will request approval from your landlord/property manager. If your landlord/
property manager approves, we will send payments directly to them to bring your rent current and pay up to 3
months of forward rent. If the landlord will not accept the funds through the program, you may be eligible to receive
assistance directly to pay your rent.
If you qualify for utility assistance, we will work with your utility company(ies). If your utility company(ies) approve,
we will send payments directly to them to bring your utilities current.
What else do I need to know?
For more information, call or text 211.
COVID-19
Emergency Rental Assistance
Tennessen Warning:
The purpose of this notice is to enable you to make an informed decision about whether to give data
about yourself. This information is being collected to facilitate the implementation of the Emergency
Rental Assistance Program, to eectively manage and evaluate the program’s eectiveness, to comply
with reporting requirements to the United States Department of Treasury, and to eciently administer
future COVID-related housing assistance programs specically authorized by the legislature or mandated
by the federal government. You are not legally required to provide any of the requested data; however,
if you do not provide the data, we may not be able to provide you with the services or resources you are
requesting. Your data may be shared between the Minnesota Housing Finance Agency, local jurisdictions
implementing the Emergency Rental Assistance Program (Anoka County, Dakota County, Hennepin County,
Ramsey County, Washington County, the City of Minneapolis, the City of Saint Paul), the United States
Department of Treasury, the program administrators and contractors, community agencies funded from
state, federal, and local resources that help provide housing assistance, and the organization(s) identied
as holding debt for which you are seeking assistance, and other parties the Minnesota Housing Finance
Agency deems necessary. The data can also be shared upon court order or provided to the state or
legislative auditor.
Privacy Act Notice:
Authority: The Minnesota Housing Finance Agency (MHFA) and the local jurisdictions (the counties of Anoka,
Dakota, Hennepin, Ramsey, and Washington, and the cities of Minneapolis and Saint Paul, collectively the
“local jurisdictions”) are authorized to collect private data, which may include your social security number if
voluntary provided, by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of
1964 (42 U.S.C. 2000d), the Fair Housing Act (42 U.S.C. 3601-19), the Minnesota Government Data Practices
Act (Minn. Stat. Ch. 13) (hereafter “MGDPA”), and by Minn. Stat. 462A.05. Purpose: Your private data, as
dened by the MGDPA, is being collected by MHFA and the local jurisdictions to determine your eligibility
toward the COVID-19 Emergency Rental Assistance Program. Other Uses: MHFA and the local jurisdictions
also use your private data to eectively manage and evaluate the program’s eectiveness, to comply with
reporting requirements to the U.S. Department of Treasury, and to eciently administer future COVID-
related housing assistance programs specically authorized by the legislature or mandated by the federal
government. Your private data may be released to federal, state, and local agencies, when relevant, and to
civil, criminal, or regulatory investigators and prosecutors. However, your private data will not be otherwise
disclosed or released outside of MHFA, the local jurisdictions, or their agents, contractors, or assigns, except
as permitted or required by law. Penalty: You must provide all of the private data required to process your
application and may provide any private data that is optional to process your application. Failure to provide
any of the required data may result in a delay or rejection of your eligibility for emergency rental assistance.
Please retain this page for your records.
RentHelpMN COVID-19
Emergency Rental Assistance
Application
If you have experienced hardship due to COVID-19
and need assistance to pay your rent or utility bills,
you may be eligible for RentHelpMN.
2 RentHelpMN COVID-19 Emergency Rental Assistance Application
To be eligible, you must answer ‘yes’ to all of the following statements:
Tenant Documentation Checklist:
Any households that cannot provide requested documentation will be contacted during the application process to
discuss options, which may cause delays in processing.
F I am a renter household in Minnesota.
F My household income meets the Program’s limits.
F Someone in your household (1) qualified for unemployment or (2) had a decrease in income or increase in
expenses due to COVID-19.
F Someone in your household is at risk for housing instability or homelessness.
To complete this application you will need to ll out all of the requested information, sign where indicated, obtain
copies of required documents, and include both the signed application and all attachments in the enclosed,
postage-paid envelope. Your application will not be processed until received. The mailing address is:
RentHelpMN
Loer Document Services
1055 American Blvd E, Suite A
Bloomington, MN 55420
Fax number: 952-285-2318
Do not send any original documents. Your application and all attachments will not be returned to you.
To process your application the RentHelpMN program needs to collect documents to show you are eligible and your
expenses can be covered. Further information can be found at RentHelpMN.org or by calling 211.
Please have ready at least one in each category:
1. Identification document for the Head of Household
State issued ID, driver’s license, passport, ITIN, Tribal ID, or other form of ID
2. Rental agreement
A signed lease, or if you do not have one a signed statement from your landlord with your rent amount, or
other documents that show you pay rent at your address
3. Income Eligibility Documents for All Adults
A signed 1040 tax return document for the year 2020, or all W2s and 1099s, or pay stubs and pay
documents for the last 2 months, or if you have no income you may self-attest.
4. Assistance Request Documents
• Past due rent statement, tenant ledger, or invoice from your landlord showing what you owe
• Past due utility bills including water, sewer, power, gas, electric, fuels, trash
• Bills for other housing expenses such as fees charged by your landlord
Assistance is provided on a fair and equal basis and the RentHelpMN program does not discriminate on
the basis of race, color, creed, religion, national origin, sex, marital status, status with regard to public
assistance, disability, familial status, gender identity or sexual orientation.
RentHelpMN COVID-19 Emergency Rental Assistance Application 3
Application
Please complete all of the following information. Once you have answered
all questions, please sign and date the application and attachments.
If you have questions about any of the requested information or required
documentation, or to request a reasonable accommodation, please call 211 for assistance.
Applicant Head of Household Information:
How can we contact you?
I am a renter.
First Name:
Field partner code:
(if none, leave blank)
Date of birth:
Phone:
Secondary phone:
Email:
Social security number:
(not required)
Tax identication number:
(not required)
Other ID number:
(not required)
Family or friend phone or
email:
Agency or case manager
phone or email:
Last Name:
4 RentHelpMN COVID-19 Emergency Rental Assistance Application
Race (select the one category that best applies to you):
Sex/Gender (check one):
American Indian – Anishinaabe / Ojibwe
Male Female
Transgender Female Transgender Male
Non-binary/Non-Conforming Not Listed or Prefer Not to Answer
American Indian – Dakota / Lakota
American Indian – Other North American Origin / Tribal Aliation
American Indian – Central or South American Origin
American Indian – Other
Asian – Hmong
Asian – Indian
Asian – Chinese
Asian – Vietnamese
Asian – Other
Black – African American (family has been in the United States for multiple generations)
Black – Somali
Black – Ethiopian
Black – Other
Pacic Islander
Hispanic/Latinx – Mexican
White – European
Hispanic/Latinx – Puerto Rican
White – Middle Eastern or North African
Hispanic/Latinx – Cuban
White – Other
Hispanic/Latinx – South or Central American
Some Other Race
Hispanic/Latinx – Spanish Origin
Multiracial – More than one broad race category applies
Hispanic/Latinx – Other
Prefer Not to Answer
Not Hispanic/Latinx
Prefer Not to Answer
Hispanic, Latinx or Spanish Origin (Select the One Category that Best Applies to You)
RentHelpMN COVID-19 Emergency Rental Assistance Application 5
Primary language (check one):
Does any member of your household have a disability?
Street Address:
Household Information:
English
My Mailing Address is the same as the property address.
Chinese
Spanish
My Mailing Address Is:
Oromo
Hmong
Other
Somali
Prefer not to answer
Karen
Yes No
I prefer not to answer
Street Address Line 1
Mailing Address Line 1
Street Address Line 2
Mailing Address Line 2
City
City
, Minnesota
Zip Code:
Zip Code:
How many people live in your household, including all adults and children?
Select one:
County:
County:
6 RentHelpMN COVID-19 Emergency Rental Assistance Application
Additional Household Members Information (names and dates of birth are only required for adults):
Additional
Household Members
CHILDREN Household Members Birth Dates Only:
Request for Additional Information
Member 1:
Member 2:
Member 3:
Member 4:
Member 5:
Member 6:
Have you applied for or received assistance from any other program such as COVID Housing Assistance Program,
local government programs, Tribal programs for the same costs you are requesting in this application?
Provide all information you have and RentHelpMN will contact your landlord
Child #1 Age Child #2 Age Child #3 Age Child #4 Age Child #5 Age Child #6 Age
First Name Last Name Date of Birth
No Yes, but I am only asking for costs that have not been paid
Property owner name:
Business name:
Email address:
Cell phone number:
Work phone number:
Landlord information:
RentHelpMN COVID-19 Emergency Rental Assistance Application 7
Landlord information, continued from page 6
Are you related to the landlord?
Provide all information you have and RentHelpMN will contact your landlord
No Yes
Mailing address state:
Contact person cell phone:
Contact person name:
Who pays this bill? (household member name):
Email address:
Total past due rent ($):
Total past due fees ($):
Mailing address zip:
Contact work phone:
As of date:
My eviction status is (check one):
Check here to request 3 future months of rent assistance (recommended):
Rent amount per month for future months:
I am behind but I have not received an eviction or lease termination notice
I have received a notice of eviction or lease termination
I have received a notice of nonrenewal of my lease
I have received an eviction summons (notice to appear in court)
I went to housing court and lost an eviction action
Please include an itemized rent due statement or ll in the attached table on page 16.
I have been served with a writ of recovery
Not Applicable
In this section please ll out all of the rent, rental fees, and utility costs you are applying to receive:
Request for Assistance
Rent Assistance
Mailing address (line 1):
Mailing address (line 2):
$
8 RentHelpMN COVID-19 Emergency Rental Assistance Application
Water or Water/Sewage (if together)
Sewer (if separate)
Electric or Electric/Gas (if together)
Gas (if separate)
This bill is paid to: Account number:
Who pays this bill?
Amount past due:
Billing period:
Is this utility disconnected?
NoYes
Utility payments:
This bill is paid to: Account number:
Who pays this bill?
Amount past due:
Billing period:
Is this utility disconnected?
NoYes
This bill is paid to: Account number:
Who pays this bill?
Amount past due:
Billing period:
Is this utility disconnected?
NoYes
This bill is paid to: Account number:
Who pays this bill?
Amount past due:
Billing period:
Is this utility disconnected?
NoYes
RentHelpMN COVID-19 Emergency Rental Assistance Application 9
Utility payments, continued from page 8
Trash
This bill is paid to:
Account number:
Who pays this bill?
Amount past due:
Billing period:
Is this utility disconnected?
NoYes
Bulk Fuels (firewood, heating oil, wood pellets, propane)
This bill is paid to: Account number:
Who pays this bill?
Amount past due:
Billing period:
Is this utility disconnected?
NoYes
Utility payments:
I am requesting assistance for the rent, utility and other costs listed in this application through RentHelpMN. I
understand any payments are subject to program eligibility, adequate verication, and available resources. The
applicant and any co-applicants and residents 18 years and older (if any) (the “Household”) authorizes all people,
entities, or organizations identied as holding a debt for which assistance is sought to share, release, discuss,
and otherwise provide all information needed to process the application, conrm the relationship and the debt
owed, and address any issues related to the application with all government entities, program administrators,
and contractors administering and/or processing applications under the COVID-19 Emergency Rental Assistance
program. The Household agrees to execute any additional release of information that may be deemed necessary to
process the application.
SIGN HERE:
10 RentHelpMN COVID-19 Emergency Rental Assistance Application
You should include all sources of income that you receive, and include the amount of income that you earn before
any deductions are taken for insurance, taxes, retirement, Medicare, etc. Your total (gross) income is what will be
considered for eligibility.
The following types of income are not included in income calculation:
• Earned income of minors (age 17 and under)
• One-time federal household stimulus payments
• Income of live-in health aids
• Non-cash benets such as childcare or medical care assistance and food support
• One-time cash gifts, for example a birthday
Household income and COVID-19 hardship
What should I include as income?
To report 2020 1040 Adjusted Gross Income (or, report Last 60 Days Income below):
First and last names:
(List all household members 18 years and over)
2020 1040
or Benet Eligibility letter
(Adjusted Gross Income)
$
$
$
Individual Applicant Request for Assistance and Duplication of Benefits
Statement, Certification, and Subrogation Agreement
Identication of Other Benets
The RentHelpMN program provides emergency assistance with rent and utility expenses and certain other expenses
related to housing incurred as a direct or indirect result of COVID-19 on behalf of renter households. The program
is federally funded and assistance can only be provided for expenses that are not otherwise being paid by a
government program. You must not request assistance for any amount of your rent or other types of assistance
sought that will be paid by another government program.
I certify that the information provided is true and accurate to the best of my knowledge. I understand that
providing false, misleading or incomplete information may result in ineligibility for this program and other
government assistance programs, repayment and recapture of funds, and other legal action. I agree to repay any
funds received through this program for expenses that are paid by another source of government assistance.
SIGN HERE:
RentHelpMN COVID-19 Emergency Rental Assistance Application 11
Any adult household members stating they receive no income must complete a Certication of No Income on page 15
Household income and hardship, continued from page 10
2020 1040 Adjusted Gross Income, continued
To report 1099, W2 or K1 income for 2020, enter the gross amount for ALL income types:
First and last names:
(List all household members 18 years and over)
Source of income:
(Business name, Social Security,
Unemployment, etc.)
Last 60 Days Gross Income
$
$
$
$
$
$
First and last names:
(List all household members 18 years and over)
2020 1040
or Benet Eligibility letter
(Adjusted Gross Income)
$
$
$
12 RentHelpMN COVID-19 Emergency Rental Assistance Application
Household income and hardship, continued from page 11
Any adult household members stating they receive no income must complete a Certication of No Income on page 15.
To report monthly income for the past 60 days, enter the gross amount for ALL income types.
Self-Certification of (I) Unemployment or (II) Decreased Income and/or Increased Expenses due, either directly
or indirectly, to COVID-19:
First and last names:
(List all household members 18 years and over)
Source of income:
(Business name, Social Security,
Unemployment, etc.)
Last 60 Days Gross Income
$
$
$
$
$
$
Since March 13, 2020, a member of my household qualies for unemployment benets.
Date most recently unemployed:
Date unemployment awarded:
Applied for unemployment:
Date of re-employment:
Since March 13, 2020, a member of my household has experienced a reduction in household income, incurred
signicant costs, or experienced other nancial hardship due directly or indirectly to the pandemic.
The hardship includes (check all that apply):
Reduction in household income
Signicant cost increases
Healthcare costs, including care at home for individuals with COVID-19
Purchase of personal protected equipment (i.e., gloves, face masks, face shields)
Penalties, fees, and legal costs associated with rental or utility payments owed
Payments for rent or utilities made by credit card
Moving costs to avoid homelessness or housing instability
Increased childcare costs
Internet access and computer costs required to work or attend school remotely
Alternative transportation costs
Forced leave from work due to school closure or childcare changes
Other
RentHelpMN COVID-19 Emergency Rental Assistance Application 13
Household income and hardship, continued from page 12
I have read and understand the Tennessen Warning and Privacy Act Notice provided with this application.
1. The income information provided is accurate and includes the income of all adults in my household from all
applicable sources.
2. I am not receiving, and have not applied for, any other source of assistance to pay for the household-related
expense(s) listed in this application.
3. The information presented in this application is complete and accurate to the best of my knowledge.
4. I certify that funds will be used for the purposes stated in the application and, if the funds are for
prospective rent, I have a reasonable expectation that, for the months I receive rental assistance, the listed
property will be my primary residence.
5. I understand that providing false representations constitutes an act of fraud. False, misleading, or
incomplete information may result in the denial of my application, the repayment of any funds received
through the RentHelpMN program, or other remedies available under law.
6. I have read and understand the Tennessen Warning given to me.
7. I understand this application is not a guarantee of assistance, that my application will be reviewed and must
meet Program eligibility guidelines, that all assistance is subject to available resources, and applications will
only be accepted while the Program is open.
8. I understand my mailed application and all attachments will be entered into the online application system
for RentHelpMN after they are received so that they may be processed for assistance.
For applicants certifying other hardship and/or housing instability, please provide additional information explaining your situation here:
The RentHelpMN COVID-19 Emergency Rental Assistance Program requires that since March 13, 2020, at least one
member of the household can demonstrate a risk of experiencing homelessness or housing instability.
Self-certification of Risk of Homelessness or Housing Instability:
Tennessen Warning and Privacy Act Notice
Final Certification of Completeness
SIGN HERE:
SIGN HERE:
TODAY’S DATE:
SIGN HERE:
Risk of eviction
Risk of lease termination
Living “doubled up”, or in a residence that isn’t permanent for you
Struggling to pay rent and utilities, or rent and utilities are more than your household can aord
Relying on credit cards or depleting savings to pay for rent or utilities
Struggling to pay for essentials such as food, prescription drugs, childcare or transportation
Other
14 RentHelpMN COVID-19 Emergency Rental Assistance Application
Rent Agreement such as lease, expired lease, letter from your landlord outlining your rental
arrangement, rent payment receipts
Rent Due Statement or Ledger from your Landlord
Income Documents that match your application:
Utility Bills
Pay Statements
Gas (if separate)
Identication such as a state-issued ID, driver’s license, Tribal ID, international ID, passport
Please include a copy of any and all documents that support your application for assistance. Do not send
original documents as they will not be returned to you.
All Applications (all that apply):
Head of Household Only:
All Adults in Household (all that apply):
1040
Water or Water/Sewage (if together)
Receipts
Trash
W2
Sewer (if separate)
Other Eligibility Letters provided by government programs or aordable housing providers
Bulk Fuels (rewood, heating oil, wood pellets, propane)
1099
Electric or Electric/Gas (if together)
Other Pay Documents
Sign the Certication of No Income, attached, for all adults with no income
Attachment Checklist
RentHelpMN COVID-19 Emergency Rental Assistance Application 15
Pay Statements
Gas (if separate)
Certification of No Income
Adult Household Member Name(s) for those certifying no income:
Within the last 12 months, did you receive income from any of the following sources?
Wages, salaries, tips, bonus, commissions, etc.
Severance pay
Worker’s compensation
Interest/dividends from assets, including bank accounts
Net income from the operation of a business or profession
Income from self-employment, including direct sales consulting (i.e. Mary Kay, Tupperware), Uber/
Lyft services, or online sales
Unemployment benets
Social Security or Supplemental Social Security Income (SSI)
Annuities, pensions, or retirement funds (i.e. IRA, 401K)
Insurance policies, disability, death benets, or similar types of periodic receipts
Alimony or child support
Regular contributions or gifts received from organizations or other persons not residing in the
dwelling (including online donations such as GoFundMe or through a local bank)
Temporary Assistance for Needy Families (TANF)
All regular pay, special pay, and allowances of a member of the Armed Forces, except the special
pay to a family member serving in the Armed Forces who is exposed to hostile re (e.g., in the past,
special pay included Operation Desert Storm)
Any other source (if yes, explain)
Yes No
Attachment Checklist
16 RentHelpMN COVID-19 Emergency Rental Assistance Application
Certification of No Income, continued from page 15
I certify that the information provided is true and accurate to the best of my knowledge. I understand that
misrepresenting household income may constitute fraud. If I indicated that my household has no income, I arm
that is accurate and I understand that I may be asked for additional information and documentation to determine
eligibility, which may delay the processing of my application. I understand that providing false, misleading or
incomplete information may result in ineligibility for this program, repayment or recapture of funds, and other legal
action.
If you have entered ‘no’ for all of the questions on the previous page, the household members indicated may
certify by signing below that they have no income.
Today’s date:
Household member 1:
SIGN HERE:
Today’s date:
Household member 2:
SIGN HERE:
Today’s date:
Household member 3:
SIGN HERE:
Today’s date:
Household member 4:
SIGN HERE:
RentHelpMN COVID-19 Emergency Rental Assistance Application 17
Past Due Rent
You may request up to 18 months of total assistance, though the award may be reduced by the program subject to
funding availability and eligibility.
Select all months where back rent and fees are owed. You may request 3 months of forward rent starting after
today’s date.
For past due rent, attach a statement or ledger or fill out the following to the best of your knowledge.
Original Amount Due
Amount I have paid
Fees due
Amount Still Due
Month
April 2020
May 2020
June 2020
July 2020
August 2020
September 2020
October 2020
November 2020
December 2020
January 2021
February 2021
March 2021
April 2021
May 2021
June 2021
18 RentHelpMN COVID-19 Emergency Rental Assistance Application
Past Due Rent, continued from page 17
July 2021
November 2021
August 2021
December 2021
September 2021
January 2022
October 2021
February 2022
Original Amount Due
Amount I have paid
Fees due
Amount Still Due
Month
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COVID-19 Emergency Rental Assistance

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Completed 5 January 2022

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