Fillable Form 1.: EmergencyRentalAssistanceProgram(ERAP) ApplicationSubmittalInstructionsandChecklist

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

EmergencyRentalAssistanceProgram(ERAP)

ApplicationSubmittalInstructionsandChecklist



Tobeeligible,ahouseholdmustbeobligatedtopayrentonaresidentialdwellingand:



ThehouseholdmustbearesidentofAdaCounty,Idaho;and

ThehouseholdmusthaveanincomethatdoesNOTexceed80%AreaMedianIncome;and



HouseholdSize 1person 2person 3person 4person 5person 6person 7person 8person

IncomeLimit

(80%AMI)

$42,200 $48,200

$54,250 $60,250 $65,100 $69,900 $74,750 $79,550



Oneormoreindividualswithinthehouseholdhasqualifiedforunemploymentbenefits;ORexperiencedareduction

inhouseholdincome,incurredsignificantcosts,orexperiencedotherfinancial hardshipdue,directlyorindirectly,to

theCOVID‐19outbreak;and

Oneormoreindividualswithinthehouseholdisatriskofexperiencinghomelessnessorhousinginstability. 



DocumentationChecklist:



 ProgramApplicationwithallquestionscomplete

 AuthorizationfortheReleaseofInformation

 IncomeDocumentation(provideallapplicabledocumentation):



Unemployment Copyofbenefitnoticeorprintoutofpaymentsreceivedforthelasttwomonths

EmploymentIncome 2020taxreturns,W2’s;ORlasttwomonthsofpaystubs

Self‐Employment

2020taxreturns,1099’s,profitandlossreportfromapplicant’saccountingsystem,

orbankstatementsforthelasttwomonths

SocialSecurityBenefits 2020taxinformationorcopyofacurrentawardletter

ChildSupport

Printoutofpaymentsreceivedforlasttwomonths,writtenverificationfromabsent

parent,orbankstatementsforthelasttwomonths

OtherIncome

Documentationfromthesourcestatingthemonthlyamountreceived.Forexample,

VApension,annuities,disabilityincome,workmen’scompensation,alimony,etc.)



 RentandUtilityAssistance:Utilitiesincludeelectricity,gas,water,sewer,trash,internet,andenergycosts,such

asfueloil.Telecommunicationservices(telephone,cable)arenot

consideredutilities.



 CurrentLeaseagreement(allpages)

 Copyofrentaldelinquencynotice(ifapplicable)

 Landlordcontactinformation

 Mostrecentutilitybill(ifrequestingassistancewithutilities)



Pleasenoteyoumaybeaskedtosubmitadditionaldocumentation.Themaximumamountofassistancehou seholdscan

receive is dependent upon need and funding availability. Return the completed application and all supporting

documentationbyemailtoerap@bcacha.org

,fax(208)345‐4909,ormailtoBoiseCity/AdaCountyHousingAuthorities

Attn:ERAP1001S.OrchardSt.Boise,ID83705.



EmergencyRentalAssistanceProgram

ApplicationandIntakeForm



Section1:PrimaryApplicantInformation



LastName:  

FirstName:     MI:  



Address: 

City: State:ZipCode:  



HomePhone#:

_Cell#: Email:  



DateofBirth://

Gender:   PreferredLanguage:    



Race

:White/CaucasianBlack/AfricanAmericanAsianAmericanIndian/AlaskanNativeNativeHawaiian/OtherPacificIslander



HispanicorLatino?

Yes NoHouseholdSize:   (Adults: Children:  )



Namesofalladulthouseholdmembers:



Namesofallminorhouseholdmembers:



Section2:COVID‐19FinancialHardshipPleasecheckALLthatapply:



 Unemployedfor90dayspriortothisapplication; 



 Suffered a substantial loss of income from

COVID‐19;



 Jobloss;



 Reduction incompensation;



 Closureofplaceofemployment;



 Obligation to be absent from work to care for

home‐boundschool‐agedchild;



 Experi enced a large unexpected medical cost 

relatedtoCOVID‐19.



 Required to be quarantined  based on diagnosis of

COVID‐19.



 Requiredtoself‐quarantinebasedontheadviceofa

healthcare provider, or the advice or directive of a

localorstatepublichealthauthority,thedirectiveof

alawenforcementofficer,orhavereasontobelieve

that self‐quarantine is in the best interest of public

healthandhumansafetyduetoan exposureorhigh‐

riskactivity.



 Otherpertinentcircumstances:



Section3:HousingStatus(checkallthatapply)



Required Documentation: Attach a copy of your current lease agreement and/or  most recent utility bill (if

applicable).



 Atriskofexperiencinghomelessness orhousinginstabilityduetoinabilitytopaypastduerentand/orutilities



 Amountofpastduerent:



 Amountofpastdueutilities:



 Atriskofexperiencinghomelessness orhousinginstabilityduetoinabilitytopayfuturerent



 Amountofrentdue:   Duedate:   



Areyoucurrentlylivinginafederallysubsidizedresidence?  

Yes No



Ifyes,pleaselisttheprogram/property:



Areyoucurrentlyreceivinganyothertypeofrent/utilityassistance?  Yes No



Ifyes,pleaselisttheprogram/agency:



Haveyouappliedforrent/utilityassistancefromanotheragency?  Yes No



Ifyes,pleaselisttheprogram/agency:



LandlordName:



Address: City: State:ZipCode:  



LandlordPhone:LandlordEmail:



RequiredDocumentation:Attachcopiesof2020W2’s,taxreturns,1099’s,ORthelasttwomonthsofpaystubsforall

adults,pensionstatement(s),socialsecurityawardletter(s),unemploymentletter(s),an d/ordocumentationofanyother

householdincome.



Onthefollowingchart,pleaselisttheGROSS(pre‐tax)monthly incomeforALLhouseholdmembers.



HouseholdMember

Name

Employment

orWages



Self‐

Employment

&Business

Income

Pension/

Retirement

Income

SocialSecurity,

Retirement,

Disability

Unemployment

TANF,other

Public

Assistance

ChildSupport,

Alimony,Foster

CarePayments

Other

Income

 

Total   

TotalMonthlyIncome: 

Thefollowinghouseholdmembershave

eroincome:



HouseholdSize: TotalAnnualHouseholdIncomefromallSources(TotalMonthlyIncomex12):  

  

(Findnumbersinyourfamilythenfollowacrossandcheckappropriateannualincomeamount)

HouseholdSize

0‐30%

ExtremelyLowIncome

 

30%‐50%

VeryLowIncome



(50%‐80%)

LowIncome

 

(Above80%)

Over

Noteligible

1person 0to$15,850 



To$26,400  To$42,200 



Over$42,200 Not eligible



2people 0to$18,100 



To$30,150  To$48,200



Over$48,200 Not eligible

3people 0to$21,960  To$33,900



To $54,250



Over$54,250 Not eligible

4people 0to$26,500 



To$37,650  To$60,250 Over$60,250 Not eligible



5people 0to$31,040



To$40,700  To$65,100  Over$ 65,100 Not eligible



6people 0to$35,580 To$43,700 To$69,900 Over$69, 900 Not eligible



7people 0to$40,120 To $46,700 To $74,750 Over $74,750 Not eligible



8people 0to$44,660 To$49,700  To $79,550  Over$79, 550 Not eligible



Section4:HouseholdIncome

0.00



Section5:AttestationandCertificationofEligibility



I,,doherebystatethatmyhouseholdhasatleastoneormoreindividualsof

my household that is obligated to pay rent on a residential dwelling and is at risk of experiencing homelessness or

housing instability, and thereby meet the housing circumstance eligibility criteria of income less than 80% AMI (Area

Median Inc

ome). My household can demonstrate this risk of experiencing homelessness or housing instability by

providingtherequisitedocumentationasrequiredinthisapplicationorattestingtoaninabilitytopayrentorutilities.

Furthermore,amemberofmyhouseholdhasaqualifyingCOVID19relatedfinancialhardship,including:

1. Qualified forunemployme

ntbenefits;OR

2. Experiencedareductioninhouseholdincome,incurredsignificantcosts,orexperiencedotherfinancial hardship

duetothenovelcoronavirusdisease(COVID‐19).

CRIMINALANDADMINISTRATIVEACTIONSFORFALSEINFORMATION



WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE WILLFUL FALSE

STATEMENTS OR MISREPRESENTATIONS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY

MATTER WITHIN ITS JURISDICTION. I UNDERSTAND THAT KNOWINGLY SUPPLYING FALSE, INCOMPLETE OR

INACCURATEINFORMATIONISPUNISHABLEUNDERFEDERALORSTATELAWSANDMAYRESULTINPROSECU

TIONAND

REPAYMENTOFASSISTANCE.



IHAVEREADTHEABOVEANDUNDERSTANDMYRESPONSIBILITIES.ICERTIFYTHATTHEINFORMATIONIHAVEGIVENIS

ACCURATE AND COMPLETE TOTHE BEST OF MYKNOWLEDGE.ICERTIFYTHAT I HAVE NOT ALREADY BEEN PROVIDED

RENTAL OR UTILITY ASSISTANCE, TH

ROUGH ANY OTHER PROGRAM, THAT COVERS THE COSTS REQUESTED IN THIS

APPLICATION.



BYCOMPLETINGANDSUBMITTINGTHISFORMIACKNOWLEDGETHATMYTYPEDNAMESHALLHAVETHESAMELEGAL

VALIDITY AND ENFORCEABILITY AS AMANUALLY  EXECUTED SIGNATURE TO THE FULLEST EXTENT PERMITTED BY

APPLICABLELAW





SignatureofPrimaryApplicantDate



ItisthepolicyofBCACHAtoseethateveryindividualregardlessofrace,religion,color,sex,age,nationalorigin,familial

status,genderidentity,sexualorientation,ordisabilityshallhaveequalopportunityinaccessingaffordabl ehousing.Ifyou

oranyoneinyourfamilyisapersonwithdisabilities, andyourequireaspecificaccommodatio

ninordertofullyutilizeour

programsandservices,pleasesubmitarequestinwritingorcontactourofficeat(208)363‐9710.

Emergency Rental Assistance Program

Authorization for the Release of Information

Last Name: MI: First Name:

Address: City: State: Zip Code:

Purpose: In signing this consent form, you are authorizing the above named organization to request information

including but not limited to: identity and marital status, income and assets, public assistance, residences and rental

activity. BCACHA needs this information to verify your eligibility for emergency rental assistance benefits. BCACHA may

participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.

Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the

consent form.

Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility for assistance.

Sources of Information: The groups or individuals that may be asked to release the authorized information include but

are not limited to:

Past/Present Employers Social Security Administration Utility Companies

Current and Prospective Landlords State Unemployment Agencies Schools and Colleges

Dept. of Health and Welfare Veterans Administration Retirement Systems

Law Enforcement Agencies Medical and Child Care Providers Previous Landlords

Support and Alimony Providers Banks and other Financial Institutions Courts & Post Offices

Alternate Contact

If you would also like us to communicate directly with another person or agency on your behalf regarding your

application, please provide us with the following information:

Agency Name:

Contact Name: Phone:

I consent to allow BCACHA to request and obtain any information from any Federal, State, or local agency,

organization, business, or individual for the purpose of verifying my eligibility and level of benefits. I have read and

understand by signing below, I certify that I am giving permission for BCACHA to obtain or share information for

emergency rent and utility assistance.

Signature of Applicant / Head of Household Date

Signature of Other Household Adult Date

Date

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Form 1.: EmergencyRentalAssistanceProgram(ERAP) ApplicationSubmittalInstructionsandChecklist

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Completed 12 August 2021

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