Fillable New York State Emergency Rental Assistance Program (ERAP) (New York State)

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New York State Emergency Rental Assistance Program (ERAP) (New York State)

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New York State Emergency Rental Assistance Program (ERAP)
Office of Temporary and Disability Assistance
Landlord Monthly Rent Confirmation Form
Instructions: Fill in the Summary Table and Monthly Table below for the months being claimed
for ERAP assistance. Note that a given month should only have applicable arrears or
prospective amounts listed – not both.
Summary Table
Tenant Name
Total Arrears Owed
$
Address
Total Prospective Amount
$
Monthly Table
Year
Month
Regular Monthly
Rent
Prospective Rent
Amount**
2020
March
$
$
April
$
$
May
$
$
June
$
$
July
$
$
August
$
$
September
$
$
October
$
$
November
$
$
December
$
$
2021
January
$
$
February
$
$
March
$
$
April
$
$
May
$
$
June
$
$
July
$
$
August
$
$
September
$
$
October
$
$
November
$
$
December
$
$
TOTALS
$
$
* Late fees are not covered by ERAP. To accept ERAP funds, late fees must be waived and will not be paid.
** Only households who are rent burdened (paying 30% or more of gross monthly income towards rent) may receive
prospective rent payments. Prospective payments are limited to three (3) months.
__________________________________________
Landlord/Property Manager Name (please print)
__________________________________________ ____________________________
Signature Date
By signing this form, the landlord or property manager attests that the Total Arrears Owed and
Total Prospective Amount listed above are true and accurate for the months, Tenant, and
Address designated above. I also attest that I have not received another payment from another
source for any of the months or amounts requested above.
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New York State Emergency Rental Assistance Program (ERAP) (New York State)

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Completed 30 July 2021

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