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SELF-CERTIFICATION OF
ORAL LEASE AGREEMENT
Caddo Parish ERA Program
Caddo Parish ERA Program
©2021 CVR Associates, Inc. All rights reserved.
If your household does not have a written lease agreement with your Landlord and has relied solely on an
oral agreement regarding the rental of your primary residence, please complete this form, sign and obtain
your Landlord’s signature as well. By completing this form, you understand that any misrepresentation in
statements may be considered fraud and punishable by law.
APPLICANT CONTACT INFORMATION
Confirmation ID: _____________________________ Applicant Name: _________________________________________________________
Address: ______________________________________________________________________________________________________________
City: ________________________________________ State: LA Zip Code: ________________________
Home Phone Number: ______________________ Cell Phone Number: __________________________
LANDLORD CONTACT INFORMATION
Landlord/Company Legal Name: ___________________________________________________________
Representative Completing Form: ___________________________________________________________
Address: __________________________________________ City, State, Zip Code: ___________________________
Phone Number: _____________________________ Email: ________________________________________________
RENTAL AGREEMENT INFORMATION
Rental Agreement Term Start Date: ____________________ Rental Term End Date (if applicable): ___________________
Rental Address: ______________________________________________________________________________________
City: ________________________________________ State: LA Zip Code: ________________________
Monthly Rent Amount (including any fees (i.e. pet, storage, garage), utilities, and/or internet included with the rent):
$______________
Agreed Upon Late Fees (if applicable) $____________ ☐ Check if No Late Fees
Late Fee Charged on the _____________ (i.e. 3
rd
, 5
th
, etc) Day of the Month If Not Paid Timely
Household Members Who Reside in the Unit (Full Name):
SELF-CERTIFICATION OF
ORAL LEASE AGREEMENT
Caddo Parish ERA Program
Caddo Parish ERA Program
©2021 CVR Associates, Inc. All rights reserved.
I, _______________________________ (Applicant), certify under penalty of perjury that the information in this certification is
true and accurate to the best of my knowledge, and that my household continues to lack sufficient funds to pay monthly
rent because of the COVID-19 pandemic, ongoing rental assistance is needed for my household, and I have not received
and I have not been approved to receive any other emergency rental assistance for the months I am requesting assistance
from this Program.
Signature: _____________________________________ Date: __________________
Applicant
I, _______________________________ (Landlord), certify under penalty of perjury that the information in this certification is
true and accurate to the best of my knowledge, and that my household continues to lack sufficient funds to pay monthly
rent because of the COVID-19 pandemic, ongoing rental assistance is needed for my household, and I have not received
and I have not been approved to receive any other emergency rental assistance for the months I am requesting assistance
from this Program.
Signature: _____________________________________ Date: __________________
Landlord
WARNING! Title 18, Section 1001 of the United States Code: Whoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the
United States, knowingly and willfully— (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious, or fraudulent
statement or representation; or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry; shall be
fined under this title, imprisoned not more than 5 years or, if the offense involves international or domestic terrorism (as defined in section 2331), imprisoned not more than 8 years,
or both. If the matter relates to an offense under chapter 109A, 109B, 110, or 117, or section 1591, then the term of imprisonment imposed under this section shall be not more than
8 years. I do hereby swear and attest that all of the information above about my household is true and correct.
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Completed 18 July 2021

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