LAKE COUNTY EMERGENCY RENTAL ASSISTANCE PROGRAM
VERIFICATION OF RENTAL HISTORY
We are requesting verification of rental history for the individual(s) named below. This individual(s)
state(s) they are a present or former tenant. Please complete this form and e-mail it to
ERA@geminus.org.
Thank you for your Cooperation.
Cordially,
LCERA
I HEREBY AUTHORIZE YOU TO RELEASE INFORMATION REGARDING MY TENANCY TO THE LAKE
COUNTY EMERGENCY RENTAL ASSISTANCE PROGRAM.
Nu
mber of Adults in Family ___________
Number of Children (under age of 18) ___________
Total Number in Household ___________
Tenant: Under penalty of perjury, I certify that the information presented in this certification is true and accurate
to the best of my knowledge. The undersigned further understand(s) that providing false representations herein
constitutes an act of fraud. False, misleading, or incomplete information may result in the termination of and the
required repayment of any, and all, benefits received through the Indiana Emergency Rental Assistance Program
and potential criminal prosecution.
____
______________________ _____________________________ __________
Tenant Name *Tenant Signature Date
*Acknowledgement: By typing your name above, you acknowledge and agree that this
represents your signature and you are attesting to all information being provided on this form.
LANDLORD ATTESTATION:
Date Tenant moved in: ______________
Monthly rent __________ Months Owed (list months and year): _______________________
_____________________________________________________________________________
Total Owed by Tenant _____________
____
________________________ _____________________________ __________
Printed Landlord Name *Landlord Signature Date
*Acknowledgement: By typing your name above, you acknowledge and agree that this
represents your signature and you are attesting to all information being provided on this form.
Landlord: Under penalty of perjury, I certify that the information presented in this certification is true and accurate
to the best of my knowledge. The undersigned further understand(s) that providing false representations herein
constitutes an act of fraud. False, misleading, or incomplete information may result in the termination of and the
required repayment of any, and all, benefits received through the Indiana Emergency Rental Assistance Program and
potential criminal prosecution.
