Fillable HOME Sample Self- Certification Of Annual Income Form (Prince George's County/Office of Information Technology and Communications)

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HOME Sample Self- Certification Of Annual Income Form (Prince George's County/Office of Information Technology and Communications)

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P
RINCE GEORGE’S COUNTY
COVID-19 E
MERGE
NCY R
E
NTA
L
ASSIS
T
ANC
E PROG
RA
M
TE
NAN
T
WRITTEN A
TTE
S
TATIO
N
OF
ELI
GIB
I
L
ITY
INS
T
RUC
T
I
O
NS:
P
lea
s
e
complete
one
for
m
and
include
the
re
qu
e
s
ted
informati
on for
all
pe
rsons
in
the
hous
ehold. C
omplete
a
n
additional
form
if
the
a
pp
licant
nee
ds
more
sp
ace
.
The
adult
hea
d of househ
old
must
s
ign
and
date
the
for
m.
P
AR
T
I: ELIGIBI
L
I
T
Y
The
eligibility
requirements
of
the
Rental
Assis
t
ance
Progr
am
are
limited
to
income
eligible
familie
s whose
annual
income
doe
s
not
excee
d 80% of
the
area
median
income,
a
s d
etermine
d by HUD. In
addition
t
o
the
income
eligibility
requirement,
a
ss
i
stance
is
limite
d
to
applicants:
▪
Where
o
ne
or
mo
r
e
individuals
within
the
hous
ehold
has
qualifie
d for un
employment
benefits
or
expe
r
ience
d
a
re
du
cti
on
in
hous
ehold
income,
inc
urr
e
d s
i
gnificant
c
osts, or
experie
n
ce
d
othe
r f
inancial
ha
rdship dur
ing
or
due
, d
irectl
y or
indirectl
y,
to
t
h
e
COVID-19 p
andemic
.
To comply with program guidelines, the applicant must indicate which eligibility category applies to their
household. Do not complete the rest of this form if the household does not meet the program’s income
limits and one of the categories below.
□Experiencing financial hardship during or due, directly or indirectly, to the coronavirus pandemic
□One or more individuals within the household has been unemployed for last 90 days
I hereby certify that I have been negatively impacted by the COVID-19 pandemic and am underemployed or
unemployed.
Check all of the below statements apply to you and/or members of your household:
⃝ You
have
bee
n
laid
off.
⃝ Your
place
of
empl
oy
ment
ha
s
closed.
⃝ You
have
e
xp
erie
n
ce
d
a
reducti
on
in
hours of work.
⃝ You mus
t
sta
y
home
to
care
for
chil
dr
e
n
due
to
closure
of
day
care
and/
or s
chool.
⃝ You
have
los
t
child
or spousa
l
suppor
t.
⃝ You
have
bee
n
unable
to
find
employment
due
to
COVID-19.
⃝ Your hous
ehold
has q
ualifie
d for
unemployment
benefits
or
experience
d
a
reducti
on
in
hous
ehold
income.
Revised
7/8/2021 Page
1
of
3
P
RINCE GEORGE’S COUNTY COVID-19 E
MERGE
NCY R
E
NTA
L
ASSIS
T
ANC
E PRO
GRAM
TE
NAN
T
WRITTEN A
TTE
S
TATIO
N
OF
ELI
GIB
I
L
ITY
o You
are
un
willing
or
unable
to
participate
in
your
previous
employment
due
to
existing
under
lyi
ng
healt
h
conditions
that
ma
y
place
you
at
a
higher
ri
sk of s
e
ve
r
e
il
lness from COVID-19,
according
to
C
D
C
guideline
s.
o Other,
plea
s
e
de
s
c
ribe
be
low.
Do you
have
a
n un
expected
increa
s
e
in
medical,
childcare
, or u
tility
expe
ns
e
s
relate
d
to
COVID-19
?
Y
e
s No
Is your r
ent
and
c
urr
entl
y
delinquent
due
to
COVID-
19?
Y
e
s
No
Ar
e
your
utilitie
s
c
urr
entl
y
delinquent
due
to
COVID-
19?
Y
e
s
No
If
ye
s, by how
ma
ny
mo
nths?
Ca
n
one
or
mo
r
e
individuals
within
the
hous
ehold demonst
rate
a
risk of
experiencing
hom
e
lessn
e
ss or housing
instability?
Y
e
s No
P
AR
T
II: TENAN
T
CER
TIF
ICA
TION/ATTE
S
TATIO
N
I
certify
und
e
r p
enalt
y of
perjur
y
that
all
of
the
in
f
ormati
on
provide
d
in
thi
s
document
is
complete
a
nd
accurate
to
the
best
of
my
knowl
e
dge
. I und
e
rsta
nd
that
Title
18, S
ecti
on 1001 of
the
U.S. C
ode
state
s
that
a
pe
rson is
guilty
of
a
felony
a
nd
a
ss
i
stance
ca
n
be
terminate
d for knowingly
a
nd w
i
llingl
y
making
a
false
or fr
audulent
statement
to
a
department
of
the
U
nite
d S
tate
s Go
vernment.
I
a
gr
ee
to
provid
e
a
ny
additional
documentati
on
require
d by DH
C
D
to
document
my/
our hous
ehold
income
.
F
urthe
r, I,
along
with
all
other
adult
membe
rs of
my
hous
ehold
who
are
on
the
lea
se,
certify
that
the
hous
ehold
income
provide
d
in
thi
s
applicati
on or furnished
to
the
landlor
d or own
e
r of
the
rental
prop
e
rty
applyi
ng on
behalf
of
my/
our Hous
ehold,
includes
the
total
hous
e
h
old
income
for
all
pe
rsons
receivi
ng w
a
ge
s or
othe
r
income
,
including
but
not
limited
to
unemployment
benefit
s
a
nd
financial
a
ss
i
stance
fr
om
fe
d
eral,
state
, or
local
age
n
cies
and/or
othe
r pr
ivate
entitie
s.
I und
e
rsta
nd
that
false
stateme
nt(s) or
in
for
mation
provide
d
to
in
my/
our
a
p
plicati
on or
to
the
landlor
d
completi
ng
thi
s
applicati
on
could
result
in
rejecti
on of
the
applicati
on. I und
ersta
nd
that
failure
to
re
po
rt
income
a
s
state
d
above
is
grounds for d
enial
fr
om
the
ERA Progr
am.
Revised
~7
/8/2021 Page
2
of
3
If
the
applicant
h
a
s
e
xp
e
r
ience
d
financial
h
a
rdship
due
to
COVID-19 p
andemic
,
the
applicant
must d
e
sc
ribe
how
the
hous
e
hold’s
fi
n
a
n
cial
sit
u
ati
on h
a
s
c
h
a
ng
e
d (
e
.g.,
lost
empl
oy
ment
or r
e
du
ce
d
income
eithe
r
tempora
r
il
y or p
ermanently).
P
RINCE GEORGE’S COUNTY COVID-19 E
MERGE
NCY R
E
NTA
L
ASSIS
T
ANC
E PRO
GRAM
TE
NAN
T
WRITTEN A
TTE
S
TATIO
N
OF
ELI
GIB
I
L
ITY
Revised
7
/8/2021 Page
3
of
3
HH
Mem
b
e
r
#
Nam
e
(L
as
t
, F
i
rs
t
,
MI)
S
i
gnatu
re
and Dat
e
(Applies to 18 yo &
over)
Relationship to
the Head of
Household
(co-head,
spouse, child,
etc.)
Date of Birth
(mm/dd/ yyyy)
Stud
e
nt
(PT/FT
,
N
ei
th
er
)
1-Elderly
(62+)
2-Disabled
3-Homeless
4-Veteran
5-Youth
(under
25)
6-Not
Applicable
Choose
#
1
H
e
a
d of
Hous
ehold
2
3
4
5
6
7
8
9
10
WARNING:
The
information
provided
on
this
form
is
subject
to
verification
at
any
time,
and
Title
18,
Section
1001
of
the
U.S.
Code
states
that
a
person
is
guilty
of
a
felony
and
assistance
can
be
terminated
for
knowingly
and
willingly
making
a
false
or
fraudulent
statement
to
a
department
of
the
United
States
Government.
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HOME Sample Self- Certification Of Annual Income Form (Prince George's CountyOffice of Information Technology and Communications)

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Completed 27 September 2021

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