Fillable Hardship Application and Payment Plan Agreement with the (Town of Telluride)

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Hardship Application and Payment Plan Agreement with the (Town of Telluride)

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File type: PDF

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Hardship Application and Payment Plan Agreement
with the Telluride Housing Authority
For Shandoka, Virginia Placer and
The Telluride Boarding House
PERSONAL INFORMATION
Last Name:
First Name:
ADDRESS:
Unit #:
Cell Phone:
Other Phone:
E-mail Address:
Number of Children in household?
Length of time living and working
in the counties of San Miguel,
West Montrose or Ouray?
Do you intend to stay in the area?
Yes
No
Hardship Payment Plan Terms and Conditions:
1. Completed Hardship Application.
2. Resident must pay at least 50% of monthly rent in any given month.
3. The remaining 50% must be paid within six months from the date of the agreement.
4. The lease will be amended to reflect this payment plan.
5. Incremental payments are encouraged.
6. Residents can utilize this program no more than 3 times.
____________________________________
______________________
___________________________________________
_____________
______________________
______________________
___________________________________________
_____________
_____________
Please select ALL THAT APPLY to your situation:
Job Loss due to COVID-19
Illness due to COVID-19
Unable to work or staying home with a child due to school closure due to COVID-19
Unable to work or staying home with an ill member of the family due to COVID-19
I can pay 50% of my rent, which is $
____________
I can pay more than 50% of my rent which is $
_____________
Please describe the circumstance which have created challenges for you being able
to pay the full month of rent: ___________________________________________
__________________________________________________________________
__________________________________________________________________
EMPLOYMENT INFORMATION:
Zip Code:
Company name of most recent employer:
Company Address:
City: State:
Manager Name:
Manager Phone number:
Are you currently employed?
Has your current company indicated you will be reemployed?
Yes
No
Yes
No
Employment (Salaries, Tips, Bonuses, etc.)
Alimony or Child Support
Welfare, TANF or Food Assistance (SNAP)
Severance Pay
Trust Funds, Annuities or Interest
Lottery Winnings, Insurance Settlements, etc.
Family Gifts
Other
Total amount of current monthly income from above sources $
What are your sources of Income?
CHECK ALL THAT APPLY
*Your employer will be contacted to verify information
__________________________________________________
___________
____________________________________________
____________________________________________
___________________
____________
____________
____________________________________________
____________________________________________
Current Monthly Expense:
CHECK ALL THAT APPLY
Rent
Electricity
Internet
Health Insurance
Car Insurance
Childcare
Child Support or Alimony
Other
Total amount of current monthly expenses $
Other Resources You Have Pursued:
CHECK ALL THAT APPLY
Housing Authority Section 8 Rental Assistance, HUD
Unemployment
Federal Stimulus Check (Received?)
Trust for Community Housing
Social Security, Disability
Temporary Assistance for Needy Families (TANF)
Food Stamps or SNAP
Social Services Emergency Funds
Good Neighbor Fund
Private Charities
Family or Friends
Victim's Compensation
Other
*
Please explain how you have exhausted all your other resources and provide us with any
other information that you feel would help determing your elegibility for this hardship
application: ___________________________________________________________
_________________________________________________________
_________________________________________________________
____________
_____________________________________________________________
Attestation
I certify that the information given on this application is accurate and complete to
the best of my knowledge. I also understand that false statements or information are
grounds for denial of assistance.
I understand that I will abide by the payment plan terms and sign an amended
lease for this payment plan. I can make incremental payments towards my rent,
plus an amortized rental payment plan at any time.
I understand that my billing statements will continue to reflect my entire balance, including
the portion of rent I am deferring.
I understand that I will not receive a late fee for entering into a payment plan unless I take
more than six months to repay the deferred rent.
I understand the THD office will temporarily halt my RentCafe account and that I will
need to pay rent by check or money order.
Applicant Signature
Co-Applicant Signature
Date
Date
Signed or Typed
Signed or Typed
Please download this application and send it to the following email: tbrier@telluride-co.gov
We will contact you within 48 hours after receiving your application.
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Hardship Application and Payment Plan Agreement with the (Town of Telluride)

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Completed 16 July 2020

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