CV-House-112 CDC Declaration to Temporary Halt Eviction Due to COVID-19 (9-2020) Page 1 of 1
Declaration Under Penalty of Perjury for the Centers for Disease Control and
Preventions Temporary Halt in Evictions to Prevent Further Spread of COVID-19
I certify under penalty of perjury, pursuant to 28 U.S.C. 1746, that the foregoing are true and correct:
I have used best efforts to obtain all available government assistance for rent or housing;
I either expect to earn no more than $99,000 in annual income for Calendar Year 2020 (or no
more than $198,000 if filing a joint tax return), was not required to report any income in 2019 to
the U.S. Internal Revenue Service, or received an Economic Impact Payment (stimulus check)
pursuant to Section 2201 of the CARES Act;
I am unable to pay my full rent or make a full housing payment due to substantial loss of
household income, loss of compensable hours of work or wages, lay-offs, or extraordinary
of-pocket medical expenses;
I am using best efforts to make timely partial payments that are as close to the full payment as
the individual’s circumstances may permit, taking into account other nondiscretionary expenses;
If evicted I would likely become homeless, need to move into a homeless shelter, or need to
move into a new residence shared by other people who live in close quarters because I have no
other available housing options.
I understand that I must still pay rent or make a housing payment, and comply with other
obligations that I may have under my tenancy, lease agreement, or similar contract. I further
understand that fees, penalties, or interest for not paying rent or making a housing payment on
time as required by my tenancy, lease agreement, or similar contract may still be charged or
I further understand that at the end of this temporary halt on evictions on December 31, 2020,
my housing provider may require payment in full for all payments not made prior to and during
the temporary halt and failure to pay may make me subject to eviction pursuant to State and
local laws.
I understand that any false or misleading statements or omissions may result in criminal and civil
actions for fines, penalties, damages, or imprisonment.
Signature of Declarant: _________________________________
Printed Name: ________________________________________
Property Address: _____________________________________
“Available government assistance” means any governmental rental or housing payment benefits available to the
individual or any household member.
An “extraordinary” medical expense is any unreimbursed medical expense likely to exceed 7.5% of one’s adjusted
gross income for the year.
“Available housing” means any available, unoccupied residential property, or other space for occupancy in any
seasonal or temporary housing, that would not violate Federal, State, or local occupancy standards and that would
not result in an overall increase of housing cost to you.