Fillable Form 1: PROGRAM DETAILS 1) Arrears: Only valid

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1
For Full Program rules and eligibility requirements, visit: HCFLGov.net/R3HomeHelp Page 1 of 1
RENTAL LEDGER
Hillsborough County Emergency Rental Assistance Program
Please download this form, complete all relevant sections, save, and upload in the portal: in the Applications table on your
dashboard, find the relevant application, click Actions, then Attach Rental Ledger to open the dialog and attach this ledger.
TENANT AND PROPERTY INFORMATION
Tenant Name
Address
Unit
Phone
City
Zip
If your lease/rental agreement does not include a full list of the tenants in the unit, please provide a full list here:
PROGRAM DETAILS
1
1) Arrears: Only valid for past due charges from March 13, 2020 or later
Prospective: Applied on a case-by-case basis, if applicable
2) Must be experiencing (or have experienced since March 13, 2020) a loss of income,
unemployment, or financial hardship due to COVID-19
3) Must be struggling with housing instability, such as being past due on your rent or at risk
of eviction
4) Ineligible to apply if receiving any other rental subsidy (such as Section 8, public housing,
HUD or other rent grants)
Example Eligible Fees (amount must be in lease greement)
Rent
Example Ineligible Fees
Cable, internet,
phone
Other utilities
Security deposits
Late fees
TOTAL AMOUNT DUE (*excluding late fees and extra charges)
$
PLEASE SELECT WHICH MONTHS HAVE NOT BEEN PAID (including future months)
Check a month below to indicate an outstanding month of rent. If partially paid, please list the unpaid amount remaining in the space below.
Current outstanding balance for each month:
*If requesting assistance with future months, please see terms and conditions for both Landlords and Tenants, since this ensures housing for
duration of the prospective payment. Otherwise, leave this portion blank for only past due payments to be considered.
LANDLORD/PROPERTY MANAGER CERTIFICATION
Landlords may be reimbursed up to the total due subject to eligibility of the applicant consistent with program rules and availability of funds.
Landlord/Property Manager Name
Rental Remittance Address
Unit
Landlord/Property Manager Phone
City
Zip
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Completed 18 May 2021

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