Fill - LANDLORD DOCUMENTATION OF RESIDENCE AND AMOUNT OF RENTAL (City of Oakland)

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RENTAL ASSISTANCE FOR MISSISSIPPIANS

EMERGENCY RENTAL ASSISTANCE (ERA) PROGRAM

LANDLORD DOCUMENTATION OF RESIDENCE AND AMOUNT OF RENTAL

OBLIGATION FORM

This form may be completed by a landlord as documentation of residence and/or documentation of

amount of the rental obligation if a household is unable to provide a current executed lease that

identifies the rental unit occupied and the rental amount owed.

Unit/Property Details:

Street Address

Apt No.

City

State

Zip

Start Date of Household’s Tenancy at this Unit/Property:

End Date of Household’s Tenancy at this Unit/Property (if known):

Documentation of Residence:

Name of Landlord:

Check the box that describes your role as landlord:

☐ I hereby certify that I am the owner of the unit/property.

☐ I hereby certify that I am the management agent of the unit/property.

Check the box that applies to this household’s circumstances:

☐ I hereby certify that the household is unable to provide a current executed lease because the

executed lease with the household has expired and no renewal was executed; however, the household

continues to reside at the unit/property.

☐ I hereby certify that the household is unable to provide a current executed lease because a lease was

not executed; however, the household has resided at the unit/property since .

Documentation of Amount of the Rental Obligation:

Frequency in which Rental Amount Owed is expected to be paid (i.e. weekly or monthly):

Rental Amount Owed per the Frequency noted above (i.e. week or month):

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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 Emergency Rental Assistance Program and/or other penalties or

remedies available under applicable law.

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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