COVID-19 RENTAL AFFIDAVIT
This form is to be completed by landlords and residential owners who have leased a room or residence to
applicants who have elected to request additional assistance and who cannot provide a general ledger, proof
of rental statements or a rental agreement. One form should be used for each applicant who has applied for
assistance through the City of Fresno COVID-19 Emergency Rental Assistance program.
Applicant Information
Applicant Name (First name, M.I., Last name): ____________________________________________________
Applicant Date of Birth: ________________________________________________________
Rental Information
I, ___________________________________________________(landlord/owner name), the landlord/owner
of the address _________________________________________________(address), do hereby attest that
_________________________________(applicant name), is a tenant at this residence and the present
obligation is as follows:
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
July 2021
August 2021
September 2021
By signing this form, I hereby certify that the above information is factual and accurate. Landlord signature
only required if they have agreed to participate in the Emergency Rental Assistance Program.
Signature of Landlord: __________________________________Date: ___________________
Applicant Certification
By signing this form, I hereby certify that the above information is factual, accurate, complete, and that I have
no proof of the rental information listed above. 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
Total
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signature
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