Please sign the document by typing your name and date.
22. Has one or more individual within the household experienced any of the following conditions
since March 31, 2020? Please check all that apply:
Been Unemployed for more than 90 days.
Qualified for unemployment benefits.
Experienced a reduction in income directly or indirectly due to COVID-19.
Incurred significant costs directly or indirectly due to COVID-19
Experienced other financial hardships directly or indirectly due to COVID-19.
None of the above apply.
Please attach documentation of the unemployment (including date of termination and name of prior
employer), approval for unemployment benefits, reduced income, and costs or other financial hardship if
you have such documentation when you submit your application.
23. Does the tenant have past due utilities?
o Yes
o No
24. If yes, list the name and contact phone number of the utility company and how much you have
accrued in arrearage since March 31, 2020 on all that apply. (If tenant pays utilities to Landlord,
put Landlord as the company name)
a. Water: Amount $ ________Company ______________ Phone _____________
Account number:_____________
b. Electricity: Amount $ ________Company ______________ Phone _____________
Account number:_____________
c. Gas: Amount $ ________Company ______________ Phone _____________
Account number:_____________
d. Sanitation: Amount $ ________Company ______________ Phone _____________
Account number:_____________
Please submit a copy of any past due and pending utility bills noted above when you submit your
application.
1. 25. If the tenant is leaving the current property, does the tenant have a new rental
agreement?
o Yes
o No
If yes, what is the name, and contact information of the new landlord? ____________________
______________________________________________________________________________
What is the monthly rent? ________________________________________________________
Please submit a copy of any documentation of said prospective rental agreement.
