COVID-19 IMPACT AFFIDAVIT
This form is to be completed by the member reporting their COVID impact. One form may be used for any
household member participating in the City of Fresno COVID-19 Emergency Rental Assistance program.
Applicant Information
Applicant Name (First name, M.I., Last name): _________________________________________________
Applicant Date of Birth: ________________________________________________________
COVID-19 Impact Information
Has the tenant or other members of the tenant household qualified for unemployment benefits, experienced
a reduction in household income, incurred significant costs, or experienced other financial hardship due to the
COVID-19 pandemic? Please check each condition that applies to the household who has lost income or
incurred significant costs due to the COVID-19 pandemic (check all that apply):
☐ Currently unemployed for 90 days
☐ Laid off-Receiving unemployment assistance
☐ Laid off-Not receiving unemployment assistance
☐Place of employment has closed
☐Reduction in hours of work
☐Must stay home for child/children due to closure of daycare or school
☐Self-employed, and business is no longer supplying income or such income has been reduced
☐Unwilling or unable to participate in previous employment due to high risk of severe illness from COVID-19
☐Reduction or elimination of child or spousal support
☐Unexpected COVID-19 related medical or funeral expense
☐Child or adult dependent care expenses increased due to COVID-19
☐ If none of the above apply, please provide a brief description of the household member’s reduction in
household income or financial hardship experienced due to the COVID-19 pandemic. Please explain:
__________________________________________________________________________________________
Household Member Signature: ____________________________________Date: _______________________
Applicant Certification
By signing this form, I hereby certify that the above information is factual, accurate, complete, and true to the
best of my knowledge. I agree to immediately notify the City of Fresno and its affiliated Administrators of any
changes to this information. I understand that as a condition of participating in this program, the City of
Fresno and its affiliated Administrators are permitted to request additional verification if the information
reported appears to be inconsistent or incorrect. I understand that if I provide any false information or
misrepresentation it will be grounds for denying my participation in the Emergency Rental Assistance
Program. In addition, my signature acknowledges my understanding and consent to the release of the
information within this document to the City of Fresno Emergency Rental Assistance Program and its affiliated
Administrators. I also understand and consent to the release of this information pursuant to the Public
Records Act, to the extent required under California law.
Applicant Signature: _____________________________________________ Date: _______________________
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