DEPENDENT CARE HARDSHIP DUE TO COVID-19
SELF-ATTESTATION FORM
I certify that I experienced a reduction in household income on or after April 1, 2020 due to the
COVID-19 pandemic based on a need to reduce hours or quit work to care for a dependent due to
the closing of a school or care facility and CAN NOT provide documentation from the list
below:
• Most recent unemployment statement during 2020/2021
• Discharge, layoff, or furlough letter
• Pay stubs showing reduction in work hours (at least 4 weeks of pay stubs must be
provided before the COVID hardship and 4 weeks during the COVID hardship)
• Pay stubs showing reduction in income (at least 4 weeks of pay stubs must be provided
before the COVID hardship and 4 weeks during the COVID hardship)
• Notice of business closure (letter from employer of closure, closure announcement in
newspaper, etc.)
• Documentation of significant costs incurred, such as child or dependent care or medical
expenses
I, __________________________ do hereby attest that at the time of this, of this application,
I have experienced a reduction in household income due to COVID-19, and am UNABLE to
provide formal documentation as listed above for verification. I certify under penalty of
perjury that the above information is complete and accurate to the best of my knowledge. The
undersigned further understand(s) that providing false representations herein constitutes an
act of fraud. False, misleading, or incomplete information may result in the termination of
and the required repayment of any benefits received through the Elkhart County Emergency
Rental Assistance Program and potential criminal prosecution including by the federal
government.
Elkhart County reserves the right to follow-up with you while your request for assistance is
being reviewed or after the processing of your application.
________________________ _________ ___________________________
First and Last Name (please print) Applicant Signature Date
INSTRUCTIONS: This form is for applicants who express they have been impacted by
COVID-19, but are unable to provide documentation of experiencing a negative economic
impact. This self-attestation form must be completed to certify an applicant’s statement of
economic hardship due to COVID-19 and be attached/uploaded to an applicant’s
application. As applicable, this form will need to be completed by an adult (age 18+) in the
household that claims they have experienced a negative economic impact due to COVID-19.
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st and Last Name
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