Fillable FORT WAYNE COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM SELF-CERTIFICATION

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FORT WAYNE COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM SELF-CERTIFICATION

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The FORT WAYNE COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM SELF-CERTIFICATION form is 2 pages long and contains:

  • 1 signature
  • 11 check-boxes
  • 5 other fields

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File type: PDF

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An Equal Opportunity Employer
FORT WAYNE COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM
SELF-CERTIFICATION OF (I) UNEMPLOYMENT OR
(II) DECREASED INCOME
AND/OR INCREASED EXPENSES
(To be completed by the Head of Household)
Since January 1, 2021, I or a member of my household has experienced a reduction in
household
income, incurred significant costs, or experienced other financial hardship
due directly or
indirectly to the COVID-19 pandemic; however, is unable to document the
hardship.
The hardship includes (check all that apply):
Reduction in Household Income Due to COVID-19:
☐ A member of my household currently qualifies for unemployment benefits due
to COVID-19
☐ Forced to take off work due to school closure or childcare change
☐ Reduction in hours of work due to COVID-19
☐ Forced to take off work due to school closure or childcare change due to
COVID-19
☐ Loss of child or spousal support
☐ Other:
Incurred Significant Costs Due to COVID-19:
□ Healthcare costs, including care at home for individuals with COVID-19
□ Payments for rent or utilities made by credit card to avoid homelessness
or
housing instability
□ Increased childcare costs
□ Alternative transportation costs for households unable to use
public transportation during the pandemic
□ Other:
An Equal Opportunity Employer
Provide additional information explaining your hardship. A form without a written
explanation will be returned to the applicant for completion:
Under penalty of perjury, I certify that the information presented in this certification is true
and accurate to the best of my knowledge. I further understand that providing false
representations
constitutes an act of fraud. False, misleading, or incomplete information may
result in the repayment of any funds received through the City of Fort Wayne’s Covid
Emergency Rental Assistance Program and other remedies
available under applicable law.
Signature of Applicant Printed Name of Applicant
Date:
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FORT WAYNE COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM SELF-CERTIFICATION

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Completed 27 March 2022

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