Fillable Hamilton County CARES Act Rent and Utility Assistance (The Village of Golf Manor)

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Hamilton County CARES Act Rent and Utility Assistance (The Village of Golf Manor)

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The Hamilton County CARES Act Rent and Utility Assistance (The Village of Golf Manor) form is 2 pages long and contains:

  • 3 signatures
  • 17 check-boxes
  • 77 other fields

Country of origin: US
File type: PDF

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Hamilton County CARES Act Rent and Utility Assistance Application
Applicant Name:
SSN:
Phone #:
Alternate Phone:
Email Address:
Application Date:
1. Have you or a member of your household suffered an adverse financial event as a result of COVID 19?
No; Yes – If yes, please describe.
2. Has that financial loss affected your ability to pay your rent or utility bills? No; Yes – If yes, please specify how, and specify
amount of rent/utilities that is owed
My family’s financial loss has affected my ability to pay rent or utility bills as described here:
The amount of rent/utilities owed is: (Must submit supporting documentation from landlord/utility provider)
Rent owed: $ Utilities owed: $
Yes
No
3.
Do you currently live in Hamilton County?
4.
Have you experienced a decrease in income due to COVID-10 pandemic?
5.
Do you have past due rent and/or utilities?
6.
Do you have the ability to pay your rent and utilities right now?
7.
Have you received other rent/utility assistance since March?
8.
Has your landlord received other payment for the past due rent/utilities?
9. Household Members (include yourself) Household members include the applicant, their children, spouse, and/or co-parent of
any child in the home.
Relationship
Age
Date of Birth
Household Income for the Past 30 Days
Employment, Child Support, Unemployment Benefits, Social Security, TANF, Alimony, Etc.
AMOUNT(S)
SOURCE(S)
HCJFS 0147 (REV. 11-20)
Reset Form
10. Please provide supporting documentation which may include:
• Unemployment letter
• Check stubs noting decrease of hours or wages
• Furlough letter
• Letter from employer showing reduction in hours/wages due to COVID-19
• Other documentation showing a reduction in income due to COVID-19
11. Have you attempted to access community resources to pay for rent/utilities? Please detail below.
Fund Source
Result
Reason
Community Action Agency
Prevention Retention
Contingency training funds
Saint Vincent DePaul
Other
APPLICANT STATEMENT
My signature below indicates that:
• I hereby certify that the information on this form is complete and accurate.
• I understand that the information provided may be subject to further verification by Hamilton County.
• If necessary, I will provide the information required to verify this data.
• If any other the information is later found be incomplete or inaccurate, I understand that I may be liable
to repay any funding paid to landlord or utility provider on my behalf.
Signature:
Date Signed:
For Office Use Only
Determination of Approval - COVID Eligibility:
Yes; No
Signature of Eligibility Determiner:
Date:
Item/Service Approved
Approval
Date
Amount
Approved
Payee institution
$
$
$
Total
$
Note: May not exceed $5000
Denial of CARES Act funding for tuition and tuition supplies and materials
Reason for Denial:
Signature of Eligibility Determiner:
Date:
HCJFS 0147 (REV. 11-20)
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Hamilton County CARES Act Rent and Utility Assistance (The Village of Golf Manor)

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Completed 27 January 2021

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