Fillable E LKHART COUNTY LANDLORD EMERGENCY RENTAL ASSISTANCE FORM

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E LKHART COUNTY LANDLORD EMERGENCY RENTAL ASSISTANCE FORM

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Landlord Emergency Rental Assistance Form & Attestation
Page 1
E
LKHART COUNTY LANDLORD EMERGENCY RENTAL
ASSISTANCE FORM & ATTESTATION
Prior to submission, with your application, make sure the following are complete:
1. Section A is complete and accurate.
2. Option 1, Option 2 or Option 3 are complete and accurate in Section
B.
3. The landlord has submitted a signed and completed W-9 to
ElkhartCountyERA@bakertilly.com or has indicated prior submittal.
SECTION A – LANDLORD AND TENANT INFORMATION
Landlord or Landlord’s Agent: _______________________
(“Landlord”) Phone number: Email:
Mailing Address:
City: State: Zip Code:
1.
Tenant. Landlord is seeking rental assistance for the following tenant’s household (“Tenant”):
First Name: Last Name:
Phone number: Email:
Mailing Address:
City: State: Zip Code:
2.
Unit. Tenant rents a rental unit and/or lot (“Tenant’s Unit”) from Landlord located at:
Rental Address: Unit #
City: State: Zip Code:
Landlord Emergency Rental Assistance Form & Attestation
Page 2
3.
Rent. Tenant pays Landlord $ per month in rent. This is the tenant paid portion of
the rent and does NOT include rental subsidies received by the tenant/landlord from federal, state or
local assistance programs such as housing choice voucher, project based rental assistance or public
housing.
4.
Past Due Rent. Tenant owes Landlord the following past due rent, including utilities paid
directly to Landlord, from April 1, 2020 through the application date: $ .
(Late fees are permitted only if legal and included in an existing lease.)
5.
Future Rent. Tenant’s rent for the next three months is:
Month ___Rent $
Month ___Rent $
Month ___Rent $
6.
Application of Funds. Landlord understands payment must be applied to the rent (including
any utilities and late fees) noted in this application. Landlord understands that Tenant may apply
for additional rent payments in 2021, up to three months at a time dependent upon fund
availability and program guidelines.
7.
No Other Governmental Rental Assistance. The above rent amounts have not been and
will not be paid by any other governmental rental assistance.
8.
No Eviction for Nonpayment. Landlord agrees not to take any action to evict Tenant for
nonpayment of rent or any related costs that have been paid to the landlord through this
program.
9.
Notification to Tenant. Landlord will provide Tenant with a copy of this form for submittal with the
tenant’s application.
10.
W-9. Landlord: submitted a W-9 to ElkhartCountyERA@bakertilly.com OR
previously submitted a W-9 with the rent relief program to
ElkhartCountyERA@bakertilly.com
11.
Multiple Tenants. Do you have other tenants who have applied or that you expect to
apply as part of this program?:
______Yes _______No
12.
Please indicate if you would like to receive rent payments on behalf of the Tenant by
direct deposit. Please note this option is only available to landlords with multiple tenants:
______Yes _______No
Landlord Emergency Rental Assistance Form & Attestation
Page 3
SECTION B – LANDLORD/TENANT ATTESTATION
OPTION A: PARTICIPATING LANDLORD ATTESTATION AND SIGNATURE
COMPLETE THIS SECTION IF YOU AGREE TO PARTICIPATE IN THE
PROGRAM
By checking this box I agree to participate in the Emergency Rental Assistance
program as outlined above and accept payment for rent owed by the tenant listed on
this form
I certify, attest, and affirm under penalty of perjury that the above information is complete and
accurate to the best of my knowledge and belief. I authorize the US Department of Treasury and
Elkhart County to verify and investigate such information with my full cooperation at any time. I
understand that providing false or misleading statements or omissions to the United States
Government and Elkhart County, on this Form and Attestation may result in federal and state
criminal and civil actions for fines, penalties, damages or imprisonment.
I have read and understand the above attestation. Landlord is signing this Form & Attestation by
electronically completing the information below or by providing a wet signature.
Signature of landlord or authorized representative of property management/rental company:
_____________________________________________________
Printed Name:__________________________________________
Entity Name and Title (if applicable):________________________
Date: __________________________________
OPTION B: NON -PARTICIPATING LANDLORD ATTESTATION AND
SIGNATURE
COMPLETE THIS SECTION IF YOU DO NOT AGREE TO PARTICIPATE IN THE
PROGRAM
I do not agree to participate in this program and understand that payment will be made
directly to the tenant.
Landlord is signing this Form & Attestation by electronically completing the information
below or by providing a wet signature.
Signature of landlord or authorized representative of property management/rental company:
_____________________________________________________
Printed Name:__________________________________________
Entity Name and Title (if applicable):________________________
Date: __________________________________
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Landlord Emergency Rental Assistance Form & Attestation
Page 4
OPTION C: TENANT ATTESTATION OF LANDLORD NON-PARTICIPATION
FOR TENANT USE ONLY IF LANDLORD WILL NOT COMPLETE ANY PORTION
OF THIS FORM.
By signing below, I certify that I have made multiple attempts to have my landlord complete
and sign this form indicating their participation in this program and willingness to accept
payment. I understand that Elkhart County or an agent acting on their behalf will also
attempt to contact my landlord for participation in the program, and if obtained, payment will
be made directly to my landlord on my behalf.
Tenant is signing this Form & Attestation by electronically completing the information below
or by providing a wet signature.
Signature of tenant/applicant applying for rental assistance funds:
_____________________________________________________
Printed Name:__________________________________________
Entity Name and Title (if applicable):________________________
Date: __________________________________
This form is required to be completed and returned with the tenant’s application for
rental assistance.
More information about the program, as well as the link to the online application are available
at:
https://elkhartcounty.com/rentalassistance
For questions please contact:
ElkhartCountyERA@bakertilly.com
317-452-8363
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E LKHART COUNTY LANDLORD EMERGENCY RENTAL ASSISTANCE FORM

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Completed 7 September 2021

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