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INSTRUCTIONS FOR DECLARATION UNDER PENALTY OF PERJURY FOR

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INSTRUCTIONS FOR DECLARATION UNDER PENALTY OF PERJURY FOR THE CDC’S
TEMPORARY HALT IN EVICTIONS TO PREVENT FURTHER SPREAD OF COVID-19
I certify that a copy of this document was provided to my landlord and/or to the owner of the property
where I live via the following method(s) (check all that apply):
☐ First Class Mail to: _______________________________________________ Date: ____________
☐ Certified Mail to: ________________________________________________ Date: ____________
Tracking Number: ________________________________________________
☐ Email to: _______________________________________________________ Date: ____________
☐ Fax to: (______) _______-_________________________________________ Date: ____________
☐ Text message to: (______) _______-_________________________________ Date: ____________
☐Hand Delivery to: (name) __________________________________________ Date: ____________
☐Other (explain): __________________________________________________ Date: ____________
Instructions to Tenants
This declaration is for tenants, lessees, or residents of residential properties who are
covered by the Centers for Disease Control and Prevention (CDC)’s order temporarily halting
residential evictions (not including foreclosures on home mortgages) to prevent the further spread of
COVID-19. Under the CDC’s order you must provide a copy of this declaration to your landlord,
property manager, or other person who has a right to have you evicted. Unless the CDC order is
extended, changed, or ended, the order prevents you from being evicted or removed from where you
are living through June 30, 2021. You are still required to pay rent and follow all the other terms of
your lease and rules of the place where you live. You may still be evicted for certain reasons other
than nonpayment of rent. This declaration is sworn testimony, meaning that you can be prosecuted,
go to jail, or pay a fine if you lie, mislead, or omit important information. Keep a copy or picture of
this declaration for your records. If you are served with an eviction court date you must still go to
court and show the judge your declaration in order to stop your eviction.
Instructions to Landlords or Other Persons with the Right to Evict
After receiving this declaration, it is a violation of the order to take “any action” to “remove or
cause the removal of a covered person from a residential property” except for one of the
permissible reasons listed in the order. A person violating the CDC Order of which this Declaration is
an attachment may be subject to a fine of no more than $100,000 if the violation does not result in a
death or one year in jail, or both, or a fine of no more than $250,000 if the violation results in a death
or one year in jail, or both, or as otherwise provided by law. An organization violating this Order may
be subject to a fine of no more than $200,000 per event if the violation does not result in a death or
$500,000 per event if the violation results in a death or as otherwise provided by law. The U.S.
Department of Justice may initiate court proceedings as appropriate seeking criminal penalties (18
U.S.C. 3559, 3571; 42 U.S.C. 271; 42 CFR 70.18).
CS323605_A 03/29/2021
OMB Control No. 1920-1303
Form Expiration: 09/30/2021
Eviction Protection Declaration
The Centers for Disease Control and Prevention (CDC) has issued an order that may protect you from being evicted or
removed from where you are living. This means that you may be able to stay at the place where you live through
JUNE 30, 2021, if you qualify.
How to use this form
1. See if you qualify for eviction protection under the CDC order. If you’d like help from an expert, contact (800) 569-4287
or go to https://www.hudexchange.info/programs/housing-counseling/rental-eviction/ to get contact information
for a local HUD-approved housing counselor.
2. Sign the declaration that you qualify, on the next page.
3. Give the signed declaration page to the individual or company you rent from (for example, building management,
landlord, etc.). Keep a picture or copy for your records and call your expert back if there’s a problem.
1. Do I qualify?
If you can check at least one box in each column, you qualify.
Column A
I received a stimulus check (Economic Impact
Payment) in 2020 or 2021
I was not required to report any income to the
IRS in 2020
In 2020 or 2021, I earned (or expect to earn)
less than $99,000 as an individual or less than
$198,000 as a joint filer
You are likely to have earned under this
amount if you receive any of the
following benefits:
• Supplemental Nutrition Assistance Program
(SNAP)
• Temporary Assistance for Needy Families
(TANF)
• Supplemental Security Income (SSI)
• Supplemental Security Disability Income
(SSDI)
None of the above —
You do not qualify.
AND Column B
I cannot pay my full rent or make a full housing
payment because:
My household income has gone
down substantially
I have been laid off from work
My work hours or wages have been cut
I have extraordinary out-of-pocket
medical expenses
1
None of the above — You do not qualify.
You checked at least one item in each column? Your income level qualifies.
[Check the first box on the next page]
1
Defined as 7.5% or more of my adjusted gross income for the year
2. My Declaration that I qualify
By checking the boxes below, I declare that each statement is true.
My income level qualifies for the reasons explained above
I have done my best to make timely partial payments that are as close as
possible to the full payment and to get government assistance in making
my rent or housing payments.
2
If I were evicted, I have no other available housing options, so I would:
• Probably become homeless, or
• Have to move to a homeless shelter, or
• Have to move in with others who live in close quarters.
I understand that after I sign:
• Unless I come to an agreement with my landlord, I am still responsible
for rent, back rent, and any fees, penalties or interest under my lease.
• I must still follow the conditions of my lease.
• Unless I come to an agreement with my landlord, if I fail to make my
required payments, I could be evicted when this temporary halt of
evictions ends.
• I can still be evicted for reasons other than not paying rent or not making
a housing payment.
I sign this declaration
3
under penalty of perjury. That means I promise that the statements
above are the truth and that I understand that I can be criminally punished for lying.
You sign here:
Date:
3. Give this signed page to the individual or company you rent from.
ATTN LANDLORDS: Thank you for your compliance. If you violate the CDC’s eviction Order, you and/
or your business may be subject to criminal penalties, including fines and a term of imprisonment.
2
Calling a local expert is the best way to figure out all the help that is available to you. Find a listing for a local HUD-approved housing counselor by calling
(800) 569-4287.
3
If you have already signed an eviction moratorium declaration, you do not need to submit another one.
Troubleshooting
tools for tenants
Find emergency rental
financial assistance
Call (800) 569-4287 to
find a listing for local
HUD-approved housing
counselors
Report problems with
debt collection
Submit a complaint to CFPB
cfpb.gov/complaint
Report discrimination
Submit a complaint.
Call HUD at (800) 669-9777
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INSTRUCTIONS FOR DECLARATION UNDER PENALTY OF PERJURY FOR

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Completed 2 September 2021

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