Fillable LOS ANGELES COUNTY COVID-19 RENT RELIEF ASSISTANCE PROGRAM (Constant Contact)

Fill Online, Printable, Fillable, Blank LOS ANGELES COUNTY COVID-19 RENT RELIEF ASSISTANCE PROGRAM (Constant Contact) Form

Use Fill to complete blank online CONSTANT CONTACT pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

LOS ANGELES COUNTY COVID-19 RENT RELIEF ASSISTANCE PROGRAM (Constant Contact)

On average this form takes 68 minutes to complete

The LOS ANGELES COUNTY COVID-19 RENT RELIEF ASSISTANCE PROGRAM (Constant Contact) form is 6 pages long and contains:

  • 0 signatures
  • 155 check-boxes
  • 198 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Constant Contact forms online.

BROWSE CONSTANT CONTACT FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HOA.102963645.1 Page 1
LOS ANGELES COUNTY COVID-19 RENT RELIEF ASSISTANCE PROGRAM
Tenant Application
Tenant(s):
Tenant Address:
Tenant Phone:
Tenant Email:
Have you provided notice to your property owner of your inability to pay rent due to the COVID-19 emergency? ☐ Yes ☐ No
Monthly Rent:
Monthly Due Date:
List month(s) with late/missed/future inability to pay rent between March 1, 2020 through
December 31, 2021
:
Lease Start Date:
Legal Property Owner:
Telephone Number:
Address City State Zip Code
Tenant(s) COVID-19 Economic Impact Certification
INSTRUCTIONS: This is a written statement documenting and certifying that Tenant(s) have experienced financial hardship as a
result of the COVID-19 pandemic. Please check all that apply to describe how the Tenant's financial situation has changed during the
period of March 1, 2020 to present (e.g., lost employment or reduced income, either temporarily or permanently).
Workplace closure or reduced hours resulting from economic impacts of COVID-19
o Tenant(s) job was terminated
o Tenant(s) was temporarily furloughed/laid off
o Tenant(s) hours and/or income was reduced
Did you become unemployed after March 1, 2020 as a result of the COVID-19 pandemic? ☐ Yes ☐ No
What was the date of separation from your employer? ____________________
Have your work hours or wages been reduced as a result of the COVID-19 pandemic? ☐ Yes ☐ No
Do you have documentation for all sources of lost income? ☐ Yes ☐ No
Suspected or confirmed case of COVID-19 or caring for a household or family member who is suspected or confirmed case of
COVID-19
Extraordinary out-of-pocket expenses for child care needs arising from school closures, out-of-pocket medical expenses, or
health care expenditures related to diagnosis and testing for and/or treatment of COVID-19 of the tenant or a member of the
tenant’s household who is suspected or confirmed case of COVID-19
Compliance with a recommendation from a government health authority to stay home, self-quarantine, or avoid congregating
with others during the state of emergency
Any additional factors relevant to the tenant household reduction in income as a result of the COVID-19 emergency
If yes, please submit the notice with your application
CASE ID#: __________________
HOA.102963645.1 Page 2
TENANT(S) HOUSEHOLD INCOME INFORMATION
TENANT(S) HOUSEHOLD MEMBERS AGE 18 AND OVER INCOME INFORMATION - To complete this statement, fill in the ALL
MONTHLY/PROJECTED ANNUAL INCOME EARNINGS for EACH TENANT AND HOUSEHOLD MEMBER AGE 18 OR OLDER listed. Each Tenant
and its Household Member must then sign this statement to certify that the information is complete and accurate, and that source
documentation will be provided upon request.
Please include all current income and income expected to be received in the next 12 months including long-term unemployment
compensation and all hazard pay. DO NOT INCLUDE IRS Economic Impact Payments (stimulus checks) or Federal Pandemic
Unemployment Compensation (the additional $600 per week).
SOURCE OF INCOME
HM # 1 HM # 2 HM # 3 HM # 4 HM # 5 HM # 6
Employment Income
Monthly Annually
$ $ $ $ $
$
Employer
Type of Business
Job Title
Self-Employed Profits
Monthly Annually
$ $ $ $ $
$
Social Security
Monthly Annually
$ $ $ $ $
$
Supplemental Security Income (SSI)
Monthly Annually
$ $ $ $ $
$
Social Security Disability (SSD)
Monthly Annually
$ $ $ $ $
$
California Work Opportunity and
Responsibility for Kids (CalWORKs)
Monthly Annually
$ $ $ $ $
$
Temporary Assistance for Needy
Families (TANF)
Monthly Annually
$ $ $ $ $
$
Pension
Monthly Annually
$ $ $ $ $
$
Alimony
Monthly Annually
$ $ $ $ $
$
Child Support
Monthly Annually
$ $ $ $ $
$
Unemployment Insurance
Monthly Annually
$ $ $ $ $
$
HOA.102963645.1 Page 3
IF YOU NEED TO INCLUDE ADDITIONAL INFORMATION, PLEASE PROVIDE ADDITIONAL PAGES
SOURCE OF INCOME HM # 1 HM # 2 HM # 3 HM # 4 HM # 5
HM # 6
Income from Assets
Monthly Annually
$ $ $ $ $
$
Interest from Bank Accounts and
Cash Funds
Monthly Annually
$ $ $ $ $
$
Monthly Annually
$ $ $ $ $
$
Other Income Not Shown Above
Sources:
$ $ $ $ $
$
NO Income
from ANY
Source
Please Check
☐ ☐ ☐ ☐ ☐
☐
HOA.102963645.1 Page 4
TENANT(S) CERTIFICATION
By signing below, I understand that making a false statement or providing false information is subject to civil and criminal
penalties, including confinement and fines under the laws of the State of California (including but not limited to California
Penal Code § 115, 118, 487, & 532 and Welfare and Institution Code § 11054) and the laws of the United States of America
(including but not limited to 18 U.S. Code 1001). Criminal charges may include but are not limited to: perjury, grand theft,
filing false documents with a public office, and obtaining money under false pretenses.
I understand that providing false information or incomplete statements are sufficient and good cause to terminate
contracts and debarment and may affect any current and future contracts. Any false information and incomplete
statements are sufficient and good cause to terminate my current participation or prohibit my future participation in any
future County and LACDA programs and may subject me to further liability and actions.
If I am determined to be eligible for this program, I will be required to submit documentation to prove my eligibility at a
later time.I acknowledge & understand that the County and
LACDA have provided no warranty or guarantee as to who will
be selected as an award recipient and waive any responsibility and liability of the County and LACDA, and all of its
departments, employees, and elected officials, from damages and losses caused by my non-selection of the requested
renter's relief and waive all errors and failures occurring during the application processing and transmissions using my
selected method of service.
Also, you will need authorization from Tenant(s) and household members to authorize County of Los Angeles/LACDA to
share any information and obtain any verification of information that is necessary to process the tenant's application for
rental assistance. This includes obtaining verification of information from and sharing information with the following
parties: Property Owner (including owner, agent, and/or property management company), organizations providing
assistance with this Program pursuant to an agreement with the County and LACDA, and their subcontractors, and others,
as necessary to implement the goals and requirements of the Program. Information will only be shared as necessary to
the above mentioned in order to effectuate the timely and full processing of the application.
TENANT(S)
HM #1 Signature
Printed Name
Date
OTHER ADULT HOUSEHOLD MEMBERS
HM #2 Signature
Printed Name
Date
HM #3 Signature
Printed Name
Date
HM #4 Signature
Printed Name
Date
HM #5 Signature
Printed Name
Date
HM #6 Signature
Printed Name
Date
HOA.102963645.1 Page 5
TENANT(S) HOUSEHOLD INFORMATION DEMOGRAPHICS
The following information is requested by the Federal Government for certain types of programs related to a dwelling in order to monitor
compliance with equal credit opportunity, and fair housing. You are not required to furnish this information, but are encouraged to do
so. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation.
TENANT(S) HOUSEHOLD INFORMATION - To complete this section, fill in the blank fields below for EACH TENANT AND HOUSEHOLD
MEMBER who lives in your home.
Household
Member Age 18
& Over
(H M #)
Name
(Last, First, MI)
Relationship to Head
of Household
(spouse, child, etc.)
Birth Date
(mm/dd/ yyyy)
Full-time
Student
Age 18+ (Y/N)
Disabled
(Y/N)
#1
Head of Household
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#2
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#3
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#4
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#5
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#6
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
HOA.102963645.1 Page 6
Household
Member
Under
Age 18
(H M #)
Name
(Last, First, MI)
Relationship to Head
of Household
(spouse, child, etc.)
Birth Date
(mm/dd/ yyyy)
Disabled
(Y/N)
#7
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#8
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#9
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#10
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#11
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
#12
ETHNICITY: RACE:
☐ Hispanic/Latino ☐White ☐ Native Hawaiian/Other Pacific Islander
☐ Not Hispanic/Latino ☐Black/ African American ☐ American Indian/ Alaskan Native
☐ Unknown ☐ Multi-Racial/Other ☐ Unknown
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

LOS ANGELES COUNTY COVID-19 RENT RELIEF ASSISTANCE PROGRAM (Constant Contact)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document