Fillable Form 2020: Landlord Monthly Rent Confirmation NYS Emergency (Microsoft)

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Form 2020: Landlord Monthly Rent Confirmation NYS Emergency (Microsoft)

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By signing this form, I, the Landlord/Property Manager, attest that all of the information provided, including
the Total Regular Monthly Rent, Total Arrears owed, and Total Prospective Amounts owed listed above are
true and accurate for the Tenant, Address, and Months designated above. I also attest that I have not
received another payment from another source for any of the months or amounts requested above.
Name, Printed: Landlord/Property Manager Signature: Landlord/Property Manager
Landlord Monthly Rent Confirmation
NYS Emergency Rental Assistance Program (ERAP) & Landlord Rental Assistance Program (LRAP)
Instructions: Fill in Tenant Name/Address and Monthly Table below for the months being claimed for ERAP/LRAP
assistance. Note that a given month should only have applicable arrears or prospective amounts listed – not both.
Tenant Name
Address
Year Month
Regular Monthly
Rent
Amount Past Due
(Arrears)*
Prospective Rent
Amount**
2020
March
$
$
$
April
$
$
$
May
$
$
$
June
$
$
$
July
$
$
$
August
$
$
$
September
$
$
$
October
$
$
$
November
$
$
$
December
$
$
$
2021
January
$
$
$
February
$
$
$
March
$
$
$
April
$
$
$
May
$
$
$
June
$
$
$
July
$
$
$
August
$
$
$
September
$
$
$
October
$
$
$
November
$
$
$
December
$
$
$
2022
January
$
$
$
February
$
$
$
March
$
$
$
April
$
$
$
May
$
$
$
June
$
$
$
July
$
$
$
August
$
$
$
September
$
$
$
October
$
$
$
November
$
$
$
December
$
$
$
$
$
$
*Late fees are not covered by ERAP/LRAP. To accept ERAP/LRAP f unds, late f ees must be waived & will not be paid.
** Only households who are rent burdened (paying 30% or more of gross monthly income towards rent) may
receive prospective rent payments. Prospective payments are limited to three (3) months.
Date:
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Form 2020: Landlord Monthly Rent Confirmation NYS Emergency (Microsoft)

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Completed 29 June 2022

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