Fillable INCOME CERTIFICATION FORM (City of Oakland)

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INCOME CERTIFICATION FORM (City of Oakland)

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RENTAL ASSISTANCE FOR MISSISSIPPIANS
EMERGENCY RENTAL ASSISTANCE (ERA) PROGRAM
INCOME CERTIFICATION FORM
This form must be completed by each household member over the age of 18 years old who (1) is
claiming the household’s income, or a portion thereof, is not verifiable due to the impact of COVID-19,
(2) receives cash income; or (3) has no income.
Income includes, but is not limited to, the following: wages, salaries, overtime pay, commissions, fees,
tips, bonuses, or other compensation for personal services; net income from the operation of a business
or profession; interest, dividends, capital gains or other net income of any kind from real or personal
property; social security, annuities, insurance policies, retirement funds, pensions, disability or death
benefits, or other types of similar periodic receipts; unemployment benefits, disability compensation,
worker’s compensation, or severance pay; welfare assistance payments; periodic and determinable
allowances, including alimony or child support payments and regular contributions or gifts received from
organizations or from persons not residing in the household; and regular pay, special pay or allowances
of a member of the armed forces.
First Name
Last Name
MI
Street Address
Apt No.
City
State
Zip
Check the box(es) that applies to your income circumstances:
☐ I hereby certify that I am unable to provide verification of my income, or a portion thereof, due to the
impact of COVID-19.
Describe how the impact of COVID-19 prevented you from providing verification of income (be
specific):
☐ I hereby certify that in 2020 I did not receive any income.
☐ I hereby certify that I do not currently receive income from any sources.
☐ I hereby certify that I receive cash income or earned cash income in 2020.
Cash income amount: $
How often do you receive this amount? ☐ Daily
☐ Weekly
☐ Bi-monthly
☐ Monthly
☐ Annually
Describe what you did to earn this cash income and the time period you earned this income (be
specific):
If this certification is completed by a caseworker or other professional with knowledge of the
household’s circumstances, please provide your:
First Name
Last Name
Describe the circumstances that required this form to be completed by casework or other
professional with knowledge of the household’s circumstances (be specific):
Under penalty of perjury, I attest that the information presented in this written attestation is true and
accurate to the best of my knowledge. I further understand that providing false representations
constitutes an act of fraud. False, misleading, or incomplete information may result in my obligation to
repay any funds received through the ERA program and/or other penalties or remedies available under
applicable law. I also give the ERA program, MHC, and their program partners permission to obtain a
copy of my tax returns from the Internal Revenue Service or Mississippi Department of Revenue and/or
any other income verification information that is necessary and that can be acquired from any Federal
or State agency in order to confirm the above.
I further understand that my household income will be reassessed every three months in order to
continue participating in the program because I am submitting a written attestation without further
documentation. I understand that the Emergency Rental Assistance Program is relying upon this
attestation to determine whether my household is eligible for the program.
Signature Date
False Claim Statement. Warning: U.S. Code, Title 31, Section 3729, False Claims, provides a civil penalty of not less than $5,000
and not more than $10,000, plus 3 times the amount of damages for any person who knowingly presents, or causes to be
presented, a false or fraudulent claim; or who knowingly makes, or caused to be used, a false record or statement; or conspires
to defraud the Government by getting a false or fraudulent claim allowed or paid.
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INCOME CERTIFICATION FORM (City of Oakland)

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Completed 22 July 2021

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