Fillable OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM (OERAP) (Oregon)

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OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM (OERAP) (Oregon)

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The OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM (OERAP) (Oregon) form is 39 pages long and contains:

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  • 61 check-boxes
  • 423 other fields

Country of origin: US
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If you have experienced hardship due to COVID-19
and need assistance to pay your rent or utility bills,
you may be eligible for OERAP.
Oregon Emergency Rental
Assistance Program Application
OREGON EMERGENCY RENTAL
ASSISTANCE PROGRAM (OERAP)
I am a renter household in Oregon.
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
To be eligible, you must answer ‘
yes’ to all of the following statements:
My household meets the Program's income limits. View page 21 for a table to determine if you meet the
Program's income limits.
Have you or anyone in your household qualified for unemployment benefits, experienced a reduction in
income, or experienced other financial hardships due to COVID-19?
Do you have a past-due rent notice, an eviction notice, or can you demonstrate housing instability or risk of
homelessness, past due utilities, and/or need assistance paying future rent or utilites?
To complete this application you will need to fill out all of the requested information, sign where indicated, obtain copies of
required documents, and include both the signed application and all attachments in a postage-paid envelope or dropped off at
your local Program Administrator's Office. Your application will not be processed until received. This application packet should be
sent to your local Program Administrator within your county. To find out the mailing address of your local Program
Administrator please review the chart on page 23.
Do not send any original documents. Your application and all attachments will not be returned to you.
Tenant Documentation Checklist
To process your application the Oregon Emergency Rental Assistance Program (OERAP) needs to collect documents to show you
are eligible and your expenses can be covered.
1. Verify Identity
(need ONE of the following)
State issued program ID or license
Passport/Birth Certificate/Social Security Card/Jail ID
An employment identification card
Certificate of marriage or license
Copy of a certified divorce decree
Copy of a certified, court-ordered maintenance award (if legal) or a notarized statement declaring separation
Single or Joint bank accounts, certified purchases or loans that show residential address
Credit report showing residence and single or joint financial activity
Military ID/VA Medical card/Certificate of Release or Discharge from Active Duty (DD214)
ODHS Benefits ledger/Social service ID
Letter from a non-profit or government agency attesting to applicant’s identification
IRS Tax forms such as a 2020 1099, 1040/1040A or Schedule C of 1040 showing amount earned and employment period
or most recent federal income tax statements
A 2020 W-2 form, if you have had the same employer for at least two years and increases can be accurately projected
Most recent paycheck stubs (consecutive: six for weekly pay, three for bi-weekly or semi-monthly pay, two for monthly
pay)
2. Verify Income
(All household members over the age of 18 must provide ONE of the following)
E L I G I B I L T Y & R E Q U I R E D D O C U M E N T A T I O N
Are you looking for rent, internet, trash, sewage, or other utility assistance for your primary rental
residence in Oregon?
1
A letter of termination from your job
Employer-generated salary report or letter stating current annual income or Earnings statements
Current bank statements
Proof of application for unemployment benefits
Proof that unemployment benefits have expired
Self Employed - tax records, statements, or other documentation of loss of employment
IF YOU HAVE NO INCOME: You can complete a Certification of No Income in the application
A current lease signed by the applicant and landlord or sub-lessor that identifies the unit where the applicant resides and
shows the rental payment amount
If you don’t have a signed lease, proof of your rent amount may include one of the following:
Bank statement, check stub or other proof that shows a pattern of paying rent
Written confirmation by a landlord who can be verified as the actual owner or management agent of where you rent
Landlord Verification of Rent Due on page 26
If landlord refuses to sign you may also submit a Self-Verification of Rent Due on page 25
Other formal attempt to collect rents or notification of rents due/outstanding
All utility bills you are claiming showing your account information and amount due
Please note: you cannot request reimbursement for expenses you have already paid
3. Verify Residence
(need ONE of the following that shows your address)
State issued program ID or license
A signed lease or written rental agreement
Utility bill showing past or current amount due
Credit report showing residence and single or joint financial activity
Official letter from third party (Landlord, Government agency, financial institution, medical institution, or school)
4. Verify Rent and/or Utility Bills Due (Including Internet, garbage, water, electric, gas and bulk fuel)
Assistance is provided on a fair and equal basis and the Oregon Emergency Rental Assistance Program does not
discriminate on the basis of race, color, creed, religion, national origin, sex, marital status, status with regard to public
assistance, disability, familial status, gender identity or sexual orientation in the provision of assistance.
2
If yes, please list:
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
A P P L I C A T I O N
Please complete all of the following information. Once you have answered all
questions, please sign and date the application and attachments.
If you have questions about any of the requested information or required
documentation, or to request a reasonable accommodation, please contact your local
Program Administrator for assistance. Find your Program Administrator on page 23.
Are you working with a culturally-specific or other community-based organization to complete this application?
Yes No
Applicant Head of Household Information:
First Name:
Last Name:
Date of Birth:
Community Partner Code:
(if none, leave blank)
I am a renter
Social Security Number:
(not required)
Tax ID Number:
(not required)
Other ID Number:
(not required)
Phone:
Secondary Phone:
Email:
Family or friend phone
or email:
Agency or case manager
phone or email:
How can we contact you?
3
Primary Race/Tribal Affiliation (Please select one):
4
American Indian – Alaska Native
American Indian – Burns Paiute of Harney County
American Indian – Central or South American Indigenous Origin
American Indian – Confederated Tribes of Grand Ronde
American Indian – Confederated Tribes of Siletz
American Indian – Confederated Tribes of Umatilla
American Indian – Confederated Tribes of Warm Springs
American Indian – Coos, Lower Umpqua and Siuslaw
American Indian – Coquille Indian Tribes
American Indian – Cow Creek Band of Umpqua Indians
American Indian – Klamath Tribes
American Indian – Other North American Indigenous Origin / Tribal Affiliation
American Indian – Unknown Indigenous Origin
Asian – Asian Indian
Asian – Chinese
Asian – Filipino
Asian – Japanese
Asian – Korean
Asian – Other (for example, Pakistani, Cambodian, or Hmong)
Asian – Vietnamese
Black or African American - African American (black individuals whose families have been in the country for multiple generations)
Black or African American - Afro-Caribbean
Black or African American - Ethiopian
Black or African American - Other Black/African American (another origin than those listed or unknown)
Black or African American - Somali
Native Hawaiian or Other Pacific Islander - Chamorro
Native Hawaiian or Other Pacific Islander - Native Hawaiian
Native Hawaiian or Other Pacific Islander - Other Pacific Islander (for example, Tongan, Fijian, or Marshallese)
Native Hawaiian or Other Pacific Islander - Samoan
White - European
White - Middle Eastern or North African
White - Other
White - Slavic
Race Not Listed
Prefer Not To Respond
Two or More Races
Ethnicity
Hispanic or Latino/a/x
Hispanic or Latino/a/x - Central American
Hispanic or Latino/a/x - Mexican
Gender
Male
Female
Transgender Female
Transgender Male
Primary Language
American Sign Language
Cantonese
English
Farsi
Filipino
Hispanic or Latino/a/x - South American
Not Hispanic or Latino/a/x - Other
Prefer Not to Respond
Nonbinary/Non Conforming
Not listed
Prefer Not To Respond
Mandarin
Russian or other Slavic
Spanish
Vietnamese
Other
Street Address:
Street Address:
Line 1
Street Address:
Line 2
City: , Oregon
Zip Code: County:
How many people are in your household, including all adults and children?
Household Information:
My mailing address is the same as the property address.
Select one:
My mailing address is different from the property address and is:
Street Address:
Line 1
Street Address:
Line 2
City: , Oregon
Zip Code: County:
5
Additional Household Members Information (names are only required for adults aged 18 and older):
Additional
Household Members
First Name Last Name Date of Birth
Member 1:
Member 2:
Member 3:
Member 4:
Member 5:
Member 6:
Member 7:
Member 8:
CHILDREN Household Members Birth Date's Only:
Child #1 Age
Child #2 Age Child #3 Age Child #4 Age Child #5 Age Child #6 Age Child #7 Age Child #8 Age
Landlord Information:
Provide all information you have and your local Program Administrator will contact your landlord to verify your information.
Please note: You
must provide your landlord's email.
Landlord/Property
Manager Company name:
Landlord/Property
Manager First name:
Landlord/Property
Manager Email:
Landlord/Property
Manager phone number:
Landlord/Property
Manager Last Name:
6
Mailing address:
Line 1
Mailing address:
Line 2
Mailing address city Mailing address state:
Mailing address zip
Landlord Information, continued:
Contact person
cell phone:
Contact person
work phone:
Contact person
name:
Email address:
Request for Assistance
Rent Assistance
Who pays this bill? (household member name):
How much do you pay for rent each month before fees? ($)
Number of bedrooms:
On the next page you will be able to list any other assistance you have received.
7
Past Due Rent
Have you received assistance from another COVID-19 rental assistance program, any local government programs, and/or Tribal
programs for the same costs you are requesting today?
No Yes, but I am only asking for costs that have not been paid.
Please check the programs you have received assistance from:
For past due rent, attach a statement or ledger or fill out the following to the best of your knowledge. You may request up to 15
months of rent starting from March 13, 2020. This 15 month total may also include up to 3 months of forward rent.
Select all months where back rent and fees are owed. You may request 3 months of forward rent starting after today’s date.
Any other Federal, State or Local Assistance Programs
Oregon Energy Assistance Program
Low-Income Energy Assistance Program (LIHEAP)
City of Portland Emergency Rent Assistance
Multnomah County Emergency Rent Assistance
Clackamas County Emergency Rent Assistance
Lane County Emergency Rent Assistance
Marion County Emergency Rent Assistance
Washington County Emergency Rent Assistance
If you are only applying for rental assistance ONLY fill out the rental assistance section. If you are only applying for utility assistance
ONLY fill out the utility section of this application.
If so, please list:
Past Due Rent, continued:
Month
Original Amount Due
Amount you paid Fees Due
March 2020
April 2020
May 2020
June 2020
July 2020
August 2020
September 2020
October 2020
November 2020
December 2020
January 2021
February 2021
March 2021
April 2021
May 2021
June 2021
Amount Paid by
Other Program(s)
Total Amount
Still Due
8
July 2021
August 2021
September 2021
October 2021
November 2021
December 2021
(if applicable)
(if you were able to
pay anything)
(hotel/motel fees, pet
fees, parking fees, etc.)
Total Rent Assistance Requested:
Utility Payments:
Water or Water/Sewage (if together)
Who pays this bill?
This bill is paid to:
Amount past due:
Account number:
Sewer (if separate)
Who pays this bill?
This bill is paid to:
Amount past due:
Number of
months past due:
Account number:
Yes
Is this utility disconnected?
No
Yes
Is this utility disconnected?
No
Number of
months past due:
9
Electric or Electric/Gas (if together)
Who pays this bill?
This bill is paid to:
Amount past due:
Account number:
Yes
Is this utility disconnected?
No
Gas (if separate)
Who pays this bill?
This bill is paid to:
Amount past due:
Account number:
Yes
Is this utility disconnected?
No
Trash
Who pays this bill?
This bill is paid to:
Amount past due:
Account number:
Yes
Is this utility disconnected?
No
Number of
months past due:
Number of
months past due:
Number of
months past due:
10
Utility Payments, continued:
Internet
Who pays this bill?
This bill is paid to:
Amount past due:
Account number:
Yes
Is this utility disconnected?
No
Number of
months past due:
Bulk Fuels (Firewood, wood pellets, propane)
Who pays this bill?
This bill is paid to:
Amount past due:
Account number:
Yes
Is this utility disconnected?
No
Number of
months past due:
Please add ALL utility assistance requested:
You may be eligible for a one-time Internet benefit of $300.00. You must provide a current Internet bill in the name of a
member of the household at the address listed for this application. You may be eligible for this benefit only after certifying
that the Internet usage is for at least one of the following purposes: (1) engage in distance learning (2) telework (3)
telemedicine (4) obtain government service, or (5) job searc
Utility Payments, continued:Individual Applicant Request for Assistance and Duplication of Benefits Statement,
Certification, and Subrogation Agreement
Oregon Emergency Rental Assistance Program (OERAP) provides emergency assistance with rent and utility expenses and certain
other expenses related to housing incurred due, directly or indirectly, to the Covid-19 outbreak to eligible renter households in its
designated award area. This program is administered by Oregon Housing and Community Services (OHCS) and is funded either
directly or indirectly through the US Department of the Treasury as part of Section 501 of Division N of the Consolidated
Appropriations Act, 2021, Pub. L. No. 116-260 (Dec. 27, 2020) (Section 501).
OHCS must implement procedures to prevent any Duplication of Benefits (DOB) as required by Section 501. With this form, an
applicant for OERAP assistance 1) outlines the OERAP assistance requested; 2) identifies other duplicative assistance received or
anticipated to be received; 3) states the OERAP funding request; 4) certifies the accuracy of the information; and 5) agrees to repay
any awarded OERAP assistance that is duplicated.
Under penalties of perjury, I/we certify that the information presented in this document is true and accurate to the best of my
knowledge and belief. I/We further understand that providing false representations herein constitutes an act of fraud. False,
misleading or incomplete information may result in my ineligibility to participate in this program or any other programs that will
accept this document. Additionally, if I/we receive future funding for the same purpose of the OERAP funds received, I/we will
agree to repay the assistance that was duplicated. Warning: Any person who knowingly makes a false claim or statement to the
U.S. Department of Treasury may be subject to civil or criminal penalties under 18 U.S.C. 287, 1001 and 31 U.S.C. 3729.
Sign Here:
11
Please refer to the total amounts requested for rental assistance on page 8 and utility assistance on page 10.
Utility Payments, continued:Household Income and COVID-19 Hardship
You should include all sources of income that you receive, and include the amount of income that you earn before any deductions
are taken for insurance, taxes, retirement, Medicare, etc. Your total (gross) income is the amount you earn before deductions are
subtracted for insurance, taxes, Medicare, fees etc. Net income is how much money is left after any deductions are subtracted.
For this application, please enter your gross income for ALL income types.
What should I include as income?
The following types of income are not included in income calculation:
Earned income of minors (age 17 and under)
One-time federal household stimulus payments
Income of live-in health aids
Non-cash benefits such as childcare or medical care assistance and food support
One-time cash gifts, for example a birthday
Option 1: Use your 2020 1040 Adjusted Gross Income
First and last names:
(List all household members 18 years and over)
2020 1040
(Adjusted Gross Income)
$
$
$
$
$
$
$
$
Option 2: Report Income using other income documents (Example: 2020 1099, W2, or 60 days of pay stubs, receipts, or deposit
slips). Each source of income should be entered separately in its own yellow box.
First and last names:
(List all household members 18 years and over)
Last 60 Days Gross Income:
$
Source of Income:
(Primary job, social security, self-
employment wages, unemployment,
alimony, child support, etc.)
$
$
12
This is the preferred option because using your 2020 taxes allows you to use your Adjusted Gross Income (which is less than your
gross income), and you only have to certify it once. All other options require you to recertify your income every 90 days.
$
Utility Payments, continued:Household Income and COVID-19 Hardship, continued:
$
$
$
$
$
$
$
13
$
$
$
$
Option 3: Self-certification of Zero Income
Any adult household members stating they receive no income in the last 30 days must complete a Certification of No
Income on page 19.
F
irst and last names:
(List all household members 18 years and over)
Last 60 Days Gross Income:
Source of Income:
(Primary job, social security, self-
employment wages, unemployment,
alimony, child support, etc.)
Option 2 (CONTINUED): Report Income using other income documents (Example: 2020 1099, W2, or 60 days of pay stubs,
receipts, or deposit slips). Each source of income should be entered separately in its own yellow box.
OERAP Assistance Request Related to COVID-19 Pandemic
The OERA Program requires that since March 13, 2020, at least one member of your household either qualifies for unemployment
benefits OR has experienced a reduction in household income, incurred significant costs, or experienced other financial hardship
due directly or indirectly to the pandemic. This means at least ONE box must be checked in either Section I. or II. below (you do not
need to check one box in each).
SELF-CERTIFICATION OF (I) UNEMPLOYMENT OR (II) DECREASED INCOME AND/OR INCREASED EXPENSES:
I. Since March 13, 2020, a member of my household qualifies for unemployment benefits
II. Since March 13, 2020, a member of my household has experienced a reduction in household income, incurred significant
costs, or experienced other financial hardship due directly or indirectly to the pandemic. The hardship includes (check all that
apply):
Date most recently unemployed: Applied for unemployment:
Unemployment Awarded:
Reduction in household income
Date of re-employment:
14
Significant cost increases
Healthcare costs, including care at home for individuals with COVID-19
Purchase of personal protected equipment (i.e., gloves, face masks, face shields)
Penalties, fees, and legal costs associated with rental or utility payments owed
Payments for rent or utilities made by credit card
Moving costs to avoid homelessness or housing instability
Increased childcare costs
Internet access and computer costs required to work or attend school remotely
Alternative transportation costs
Forced leave from work due to school closure or childcare changes
Other
OERAP Assistance Request Related to COVID-19 Pandemic, continued:
SELF-CERTIFICATION OF (III) RISK OF HOMELESSNESS OR HOUSING INSTABILITY:
The OERA Program requires that since March 13, 2020, at least one member of my household has experienced/can demonstrate
an increased risk of homelessness or housing instability.
III. A member of my household has experienced an increased risk of homelessness or housing instability. (The hardship does
not need to exist as of the date of the application as long as it existed for any period of time since March 13, 2020. For
example, if one member of your household faced a risk or eviction or lived in an overcrowded situation between March 13,
2020 and August 1, 2020, your household would be eligible for OERAP assistance under this eligibility criteria.):
The hardship includes (check all that apply):
Risk of eviction
Under penalty of perjury, I certify that the information presented in this certification 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 the repayment of any funds received through the OERA Program and other remedies available under
applicable law.
Sign Here:
15
Risk of lease termination
Living “doubled up” or in a residence that isn’t permanent for you
Struggling to pay rent and utilities, or rent and utilities are more than your household can afford
Relying on credit cards and/or depleting savings to pay for rent or utilities
Struggling to pay for essentials such as food, prescription drugs, childcare, or transportation
Displaced due to the 2020 wildfires and still in need of housing assistance
Other
Privacy Policy:
Oregon Housing and Community Services (OHCS) is committed to assuring the privacy of individuals and families who have
contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all of
the information (Personal Information) you share with OHCS, both orally and in writing, will be managed in accordance with
applicable state and federal laws. While your Personal Information is exempt from disclosure under Oregon’s Public Records laws,
ORS 192.355(24), your Personal Information will be shared when required by applicable law and to the extent needed to
administer the Oregon Emergency Rental Assistance Program (OERAP). If your Personal Information is required to be disclosed
with third-parties, it will only be shared if you authorize and sign the Third Party Authorization for Release of Information Tab.
Please note, however, if you do not sign the Third Party Authorization for Release of Information, you will not be eligible to apply
for OERAP funds. If you do sign the Authorization for Release, your Personal Information will be shared as follows:
Disclosure within OHCS: Your personal information will be shared only with those OHCS employees who have a need to know your
Personal Information in order to provide you with OHCS services including, without limitation, reviewing, processing your
application for Oregon Emergency Rental Assistance Program (OERAP) funds, administering the OERAP in accordance with
applicable law, and counseling you about the OERAP and options relating to the Program. OHCS may also use your Personal
Information in aggregate, anonymous form for the purpose of: (i) research, (ii) evaluating our OHCS services, (iii) designing future
OHCS programs.
Disclosure to OHCS agents and Subcontractors: Your Personal Information will be shared with OHCS agents and subcontractors
only to the extent necessary for such parties to assist OHCS with processing your OERAP application, counseling you about the
OERAP and options relating to the Program, and administering the OERAP in accordance with applicable law. OHCS agents and
subcontractors are bound by the same obligation of confidentiality as OHCS and shall treat and protect your Personal Information
as OHCS does.
Disclosure to other governmental agencies, entities, authorities: OHCS and its agents and Subcontractors will disclose your
Personal Information to other governmental agencies, entities, or authorities: (i) as necessary to comply with the administration of
the OERAP (for example and without limitation, federal assistance reporting requirements), (ii) if compelled to do so by applicable
law (for example, in response to a subpoena from a court or other authority of competent jurisdiction), and (iii) to ensure there is
no duplication of benefits.
Disclosure to other third-parties: OHCS and its agents and Subcontractors will disclose your Personal Information to your landlord,
property management company, and utility companies (including internet providers) only to the extent necessary to verify and
process your application. OHCS will disclose your Personal Information to other third parties if compelled to do so by applicable law
(for example, in response to a subpoena from a court or other authority of competent jurisdiction). In addition to limiting the
disclosure of your Personal Information as described above, OHCS computer systems, networks, and its third-party application
service providers employ physical, electronic, and procedural safeguards that comply with applicable federal and state laws that
have been enacted or adopted for the purpose of protecting your Personal Information from being disclosed to unauthorized
parties.
Sign Here:
16
Affidavit Statements
Under penalty of perjury, I/we certify that all of the information in this affidavit is truthful and the event(s) identified above
has/have contributed to my/our need for assistance.
I/we understand and acknowledge that OHCS and/or its agents may investigate the accuracy of my/our statements, may
require me/us to provide supporting documentation, and that knowingly submitting false information may violate Federal
and/or state law.
I/we understand that if I/we have engaged in fraud or misrepresented any fact(s) in connection with this OERAP Affidavit, or if
I/we do not provide all of the required documentation, that OHCS may seek additional information for verify accuracy and/or I
may be disqualified for assistance.
I/we understand that the OERAP funds are not intended to duplicate any other funds I/we have received for the same
expenses, and I/we certify that I/we have not received duplicate benefits from any other source for the funding I/we are
requesting in this OERAP application.
I/we understand that OHCS and/or its agents will use this information to evaluate my/our eligibility for assistance, but OHCS
and its agents are not obligated to offer me/us assistance based solely on the representations in this affidavit.
I/we understand that OERAP assistance is only available for primary residences, and I/we hereby confirm that the address
listed in my/our application is our primary residence.
1.
2.
3.
4.
5.
6.
Read each statement and sign to agree at the bottom of the form for each household member:
Privacy and protection of personal information:
I understand that the submission of an application does not guarantee OERAP assistance.
I hereby authorize OHCS and its employees and agents to discuss, share, release and otherwise provide information about my
rental history, utility payment status, employment, and financial and rent situation as it is necessary to seek solutions to my
housing and/or utility problem, and as necessary to prevent a duplication of benefits.
I understand that this information will be treated as confidential and that access to this information will be limited to those
who are directly involved in assisting with my application.
I understand OHCS may provide certain information not covered under applicable privacy laws to be reported to the United
States Department of the Treasury or its successors or assigns for limited reporting purposes related to federal housing
programs.
I consent to being contacted concerning this request for rental assistance at any mobile telephone number or address I have
provided. This includes email addresses, text messages, and telephone calls to my mobile telephone.
1.
2.
3.
4.
5.
Application process:
I understand that I do not automatically qualify for OERAP assistance by submitting an application or any additional forms or
documents requested by OHCS, their assignees or agents.
I understand that this is only an application for assistance and that the OHCS and its agents or its assignees will consider
additional factors in reviewing my application.
I understand that my application may not meet applicable criteria and that I will be notified in writing via mail, email, or
through the online application, of my application's acceptance or denial.
I certify that I am willing to provide all requested documents and to respond to all communications from OHCS and its partners
in a timely manner.
I authorize OHCS, its agents, and its assignees to review and verify information contained in my OERAP application at any time.
I understand that I may be audited by OHCS or its assignees and agree to provide requested documents in a timely manner or
risk termination or repayment of my assistance.
I agree to provide OHCS immediate notice if I move before the last day of the month for which I have received OERAP
assistance for future rent. In such case, the party receiving the prospective rent (either me or the landlord) will be responsible
for repaying all or a portion of the prospective rent.
Applicant acknowledges that if OHCS or any of its partners determine that any information submitted by the applicant is
incorrect or inaccurate, the information may be adjusted by OHCS or its partners.
1.
2.
3.
4.
5.
6.
7.
8.
17
click to sign
signature
click to edit
Affidavit Statements, continued:
I have described my current financial condition, and certify that all information presented herein, as well as attachments are
true, accurate, and correct to the best of my knowledge.
I understand that false or misleading information will affect my ability to receive assistance and may be grounds for rejection
of my application or termination of assistance I may receive.
I understand that false or misleading information may result in a request for immediate repayment of any assistance that I
receive.
I/we also understand that knowingly submitting false information may violate Federal law.
1.
2.
3.
4.
Fraud:
Disclaimer/Limitation of Liability:
You agree to defend, indemnify and hold harmless OHCS and its assignees ("Agency") and its affiliates, subsidiaries, agents, and
their respective officers, directors, employees, and agents from and against all claims, liabilities, costs, and expenses arising under
any representation or warranty made by the Agency; your failure to comply with the Terms and Conditions', your negligence,
actions, or omissions; your violation or alleged violation of the rights of a third party. Under no circumstances will OHCS or its
assignees be liable for any lost profits, lost opportunity or any direct, consequential, incidental, special, punitive, or exemplary
damages arising out of your use of or inability to use OHCS site or its services or programs, even if the OHCS has been apprised of
the likelihood of such damages occurring and regardless of the form of action, whether in contract, warranty, tort (including
negligence), strict liability, or otherwise. This includes any damages or losses based on any statement, representation, negligence,
action, or omission by any housing counselor or their employees or their agents.
Sign Here:
Third Party to Contact Servicer or Property Management Company:
The Applicant and any co-applicants and residents 18 years and older (if any) named below (individually and collectively, "Borrower
Applicant") authorize all Third Party vendors present on this application; and the Third Parties assisting OHCS in the review of the
OERAP applications (Individually and collectively, "Third Party") to share, release, discuss, and otherwise provide to and with each
other public and non-public personal information contained in or related to the lease, utilities, and/or the OERAP application of the
Applicant.
Sign Here:
18
Sign Here:
Certification of No Income:
Adult Household Member Name(s) for those certifying no income:
Within the last 30 days, did you receive income from any of the following sources?
Wages, salaries, tips, bonus, commissions, etc.
Severance pay
Worker’s compensation
Interest/dividends from assets, including bank accounts
Net income from the operation of a business or profession
Income from self-employment, including direct sales consulting (i.e. Mary Kay, Tupperware), Uber/Lyft services, or
online sales
Unemployment benefits
Social Security or Supplemental Social Security Income (SSI)
Annuities, pensions, or retirement funds (i.e. IRA, 401K)
Insurance policies, disability, death benefits, or similar types of periodic receipts
Alimony or child support
Regular contributions or gifts received from organizations or other persons not residing in the dwelling (including
online donations such as GoFundMe or through a local bank)
Temporary Assistance for Needy Families (TANF)
All regular pay, special pay, and allowances of a member of the Armed Forces, except the special
pay to a family member serving in the Armed Forces who is exposed to hostile fire (e.g., in the past,
special pay included Operation Desert Storm)
Any other source (if yes, explain)
19
Certification of No Income, continued:
If you have entered ‘no’ for all of the questions on the previous page, the household members indicated may certify by signing
below that they have no income.
Under penalty of perjury, I certify that the information presented in this certification 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 the repayment of any funds received through the OERA Program and other remedies available under
applicable law. I also give the OHCS and its partners permission to obtain a copy of any tax returns from the Internal Revenue
Service and to verify income and other information provided herein from other State agencies.
Household member 1:
Sign here:
Household member 2:
Sign here:
Household member 3:
Sign here:
Household member 4:
Sign here:
Household member 5:
Sign here:
Household member 6:
Sign here:
Household member 7:
Sign here:
Household member 8:
Sign here:
20
A current lease signed by the applicant and landlord
or sub-lessor that identifies the unit where the
applicant resides and shows the rental payment
amount
If you don’t have a signed lease, proof of your rent
amount may include one of the following:
Bank statement, check stub or other proof that
shows a pattern of paying rent
Written confirmation by a landlord who can be
verified as the actual owner or management
agent of where you rent
Landlord Verification of Rent Due on page 26
If landlord refuses to sign you may also submit a
Self-Verification of Rent Due on page 25
Other formal attempt to collect rents or
notification of rents due/outstanding
All utility bills you are claiming showing your account
information and amount due
Please note: you cannot request reimbursement for
expenses you have already paid
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
A T T A C H M E N T C H E C K L I S T
Please include a copy of any and all documents that support your application for assistance.
Do not send original documents as they will not be returned to you.
1. Verify Identity
(need ONE of the following)
3. Verify Residence
(need ONE of the following that shows your address)
State issued program ID or license
A signed lease or written rental agreement
Utility bill showing past or current amount due
Credit report showing residence and single or joint
financial activity
Official letter from third party (Landlord,
Government agency, financial institution, medical
institution, or school)
4. Verify Rent and/or Utility Bills Due (Including
Internet, garbage, water, electric, gas and bulk fuel)
Note: There are alternative options for documentation of application requirements for those
that cannot produce some or all of these materials; please proceed with the application if you
are eligible.
State issued program ID or license
Passport/Birth Certificate/Social Security Card/Jail ID
An employment identification card
Certificate of marriage or license
Copy of a certified divorce decree
Copy of a certified, court-ordered maintenance award (if
legal) or a notarized statement declaring separation
Single or Joint bank accounts, certified purchases or loans
that show residential address
Credit report showing residence and single or joint financial
activity
Military ID/VA Medical card/Certificate of Release or
Discharge from Active Duty (DD214)
ODHS Benefits ledger/Social service ID
Letter from a non-profit or government agency attesting to
applicant’s identification
IRS Tax forms such as a 2020 1099, 1040/1040A or
Schedule C of 1040 showing amount earned and
employment period or most recent federal income tax
statements
A 2020 W-2 form, if you have had the same employer
for at least two years and increases can be accurately
projected
Most recent paycheck stubs (consecutive: six for
weekly pay, three for bi-weekly or semi-monthly pay,
two for monthly pay)
A letter of termination from your job
Employer-generated salary report or letter stating
current annual income or Earnings statements
Current bank statements
Proof of application for unemployment benefits
Proof that unemployment benefits have expired
Self Employed - tax records, statements, or other
documentation of loss of employment
IF YOU HAVE NO INCOME: You can complete a
Certification of No Income in the application
2. Verify Income
(All household members over the age of 18 must
provide ONE of the following)
21
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signature
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22
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
A R E A M E D I A N I N C O M E C H A R T
For more information review the Department of Housing and Urban Development's
Income Limits
County
1 Person 2 People 3 People 4 People 5 People 6 People 7 People 8 People
Baker County
Benton County
Clackamas County
Clatsop County
Columbia County
Coos County
Crook County
Curry County
Deschutes County
Douglas County
Gilliam County
Grant County
Harney County
Hood River County
Jackson County
Jefferson County
Josephine County
Klamath County
Lake County
Lane County
Lincoln County
Linn County
Malheur County
Marion County
Morrow County
Multnomah County
Polk County
Sherman County
Tillamook County
Umatilla County
Union County
Wallowa County
Wasco County
Washington County
Wheeler County
Yamhill County
$36,050
$47,600
$54,150
$40,850
$54,150
$36,050
$36,050
$36,050
$45,050
$36,750
$36,050
$36,050
$36,050
$42,150
$38,300
$36,050
$36,450
$36,050
$36,050
$39,900
$36,050
$37,650
$36,050
$39,600
$36,900
$54,150
$39,600
$37,600
$36,050
$38,400
$36,050
$36,900
$38,400
$54,150
$36,050
$54,150
$41,200
$54,400
$61,900
$46,650
$61,900
$41,200
$41,200
$41,200
$51,450
$42,000
$41,200
$41,200
$41,200
$48,150
$43,750
$41,200
$41,650
$41,200
$41,200
$45,600
$41,200
$43,000
$41,200
$45,250
$42,150
$61,900
$45,250
$43,000
$41,200
$43,850
$41,200
$42,150
$43,850
$61,900
$41,200
$61,900
$46,350
$61,200
$69,650
$52,500
$69,650
$46,350
$46,350
$46,350
$57,900
$47,250
$46,350
$46,350
$46,350
$54,150
$49,200
$46,350
$46,850
$46,350
$46,350
$51,300
$46,350
$48,400
$46,350
$50,900
$47,400
$69,650
$50,900
$48,350
$46,350
$49,350
$46,350
$47,400
$49,350
$69,650
$46,350
$69,650
$51,500
$68,000
$77,350
$58,300
$77,350
$51,500
$51,500
$51,500
$64,300
$52,500
$51,500
$51,500
$51,500
$60,150
$54,650
$51,500
$52,050
$51,500
$51,500
$56,950
$51,500
$53,750
$51,500
$56,550
$52,650
$77,350
$56,550
$53,700
$51,500
$54,800
$51,500
$52,650
$54,800
$77,350
$51,500
$77,350
$55,650
$73,450
$83,550
$63,000
$83,550
$55,650
$55,650
$55,650
$69,450
$56,700
$55,650
$55,650
$55,650
$65,000
$59,050
$55,650
$56,250
$55,650
$55,650
$61,550
$55,650
$58,050
$55,650
$61,100
$56,900
$83,550
$61,100
$58,000
$55,650
$59,200
$55,650
$56,900
$59,200
$83,550
$55,650
$83,550
$59,750
$78,900
$89,750
$67,650
$89,750
$59,750
$59,750
$59,750
$74,600
$60,900
$59,750
$59,750
$59,750
$69,800
$63,400
$59,750
$60,400
$59,750
$59,750
$66,100
$59,750
$62,350
$59,750
$65,600
$61,100
$89,750
$65,600
$62,300
$59,750
$63,600
$59,750
$61,100
$63,600
$89,750
$59,750
$89,750
$63,900
$84,350
$95,950
$72,300
$95,950
$63,900
$63,900
$63,900
$79,750
$65,100
$63,900
$63,900
$63,900
$74,600
$67,800
$63,900
$64,550
$63,900
$63,900
$70,650
$63,900
$66,650
$63,900
$70,150
$65,300
$95,950
$70,150
$66,600
$63,900
$68,000
$63,900
$65,300
$68,000
$95,950
$63,900
$95,950
$68,000
$89,800
$102,150
$77,000
$102,150
$68,000
$68,000
$68,000
$84,900
$69,300
$68,000
$68,000
$68,000
$79,400
$72,150
$68,000
$68,750
$68,000
$68,000
$75,200
$68,000
$70,950
$68,000
$74,650
$69,500
$102,150
$74,650
$70,900
$68,000
$72,350
$68,000
$69,500
$72,350
$102,150
$68,000
$102,150
A household of 2 people living in Clackamas County must make less than $61,900 to be eligible for
OERAP assistance.
To receive Oregon Emergency Rental Assistance, your household income may not exceed 80% of the
Area Median Income (AMI) for the area in which your household is located. Please review the table
below to find your county and household size to see what the income limit is in your area.
For example:
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23
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
C O N T A C T I N F O R M A T I O N F O R L O C A L P A R T N E R S
NeighborImpact (NI)
https://www.neighborimpact.org/get-help/get-housed/rent-assistance-programs/
541-548-2380 x 210
County
Community Connection of NE Oregon (CCNO)
https://ccno.org/ | 541-523-6591 | 2810 Cedar Street, Baker City, OR 97814
Community Services Consortium (CSC)
https://communityservices.us/rentrelief-application/ | 541-704-7506
250 Broadalbin St. SW, Suite 2A, Albany, OR 97321
Clackamas County Social Services Division (CCSSD)
https://www.clackamas.us/communitydevelopment/cha | 503-655-8575
2051 Kaen Rd. unit 135 Oregon City, Or 97045
Baker
Benton
Clackamas
Coos
Oregon Coast Community Action (ORCCA)
https://www.orcca.us |541-435-7080 (ext 370) | 1855 Thomas Ave Coos Bay, OR 97420
Crook
Curry
Deschutes
Douglas
United Community Action Network (UCAN)
https://www.ucancap.org/index.php/additional-help | 541-672-3524
280 Kenneth Ford Drive, Roseburg, OR 97470
Gilliam
Community Action Program of East Central Oregon (CAPECO)
https://www.capeco-works.org/housing.html | 541-276-1926 |
721 SE 3rd St, Suite D, Pendleton, OR 97801
Grant
Community Connection of NE Oregon (CCNO)
https://www.ccno.org | 541-575-2949 | 142 NE Dayton, John Day, OR 97850
Harney
Communities in Action (CinA)
https://www.communityinaction.info | 541-889-9555 | 915 SW 3rd Ave, Ontario, OR 97914
Jackson
ACCESS
https://www.accesshelps.org | 541-414-0319 | 3630 Aviation Way Medford, OR 97504
Jefferson
Contact Information
Hood River
Clatstop
Columbia
Crook
Community Action Team (CAT)
https://ccaservices.org/ | 503-325-1400 | 364 9th St., Clatsop, OR 97146
Community Action Team (CAT)
https://www.cat-team.org/ | 503-397-3511 | 125 N. 17th St., Saint Helens, OR 97051
NeighborImpact (NI)
https://www.neighborimpact.org/covid-rent-relief/ | 541-323-0222
1855 Thomas Ave Coos Bay, OR 97420
Mid-Columbia Housing Authority (MCHA)
https://www.mid-columbiahousingauthority.org/covid-19-resources-2/| 541-296-5462
500 E 2nd St. The Dalles, OR 97058
Oregon Coast Community Action (ORCCA)
https://www.orcca.us |541-435-7080 (ext 370) | 1855 Thomas Ave Coos Bay, OR 97420
NeighborImpact (NI)
https://www.neighborimpact.org/covid-rent-relief/ | 541-323-0222
NeighborImpact, 2303 SW First St., Redmond, OR 97756
NeighborImpact (NI)
https://www.neighborimpact.org/covid-rent-relief/ | 541-323-0222
NeighborImpact, 2303 SW First St., Redmond, OR 97756
The Oregon Emergency Rental Assistance Program (OERAP) is funded by OHCS and is provided through local Program
Administrators. Each has received funding to distribute within their service regions. You can find a list of providers
and information on how to access these funds below.
Josephine
United Community Action Network (UCAN)
https://www.ucancap.org/index.php/additional-help | 541-672-3524
280 Kenneth Ford Drive, Roseburg, OR 97470
24
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
C O N T A C T I N F O R M A T I O N F O R L O C A L P A R T N E R S
Marion
Mid-Willamette Valley Community Action Agency (MWVCAA)
https://mwvcaa.org/programs/the-arches-project/covid-rent-relief/ | 503-399-9080 - Dial 1
ARCHES Project, 615 Commercial Street NE, Salem OR 97301
Morrow
Multnomah
CALL: 211 or 1-866-698-6155 (Language interpreters available by phone) TTY: dial 711 and
call 503-988-0466 TEXT: your zip code to 898211 (TXT211) (text/email in English and Spanish)
https://multco.us/multnomah-county/covid-19-rent-assistance-and-housing-stability-resources
209 SW 4th Avenue, Suite 200 Portland, OR 97204
Sherman
Polk
Umatilla
Union
Community Connection of NE Oregon (CCNO)
https://www.ccno.org | 541-963-7532 | 1504 N Albany St, La Grande, OR 97850
Wallowa
Community Connection of NE Oregon (CCNO)
https://www.ccno.org | 541-426-3840 | 702 NW 1st St, Enterprise, OR 97828
Washington
Community Action Organization (CAO) | 1001 SW Baseline St. Hillsboro, OR 97123
https://caowash.org/programs/housing-stability/renter-support.html | 503-615-0770
Wheeler
Lincoln
Community Services Consortium (CSC)
https://communityservices.us/rentrelief-application/ | 541-704-7506
250 Broadalbin St. SW, Suite 2A, Albany, OR 97321
Linn
Malheur
Lake
Lane
Lane County Human Services Division (LCHSD)
http://www.lanecounty.org/rent | 541-682-3776 | 151 W. 7th Ave Suite 560, Eugene OR 97401
Wasco
Klamath and Lake Community Action Services (KLCAS)
http://www.klcas.org | 541-882-3500 | 535 Market Street, Klamath Falls, OR 97601
Klamath
Tillamook
Community Action Team (CAT)
careinc.org | 503-842-5261 | 2310 1st St., Ste 2, Tillamook, OR 97141
County Contact Information
Klamath and Lake Community Action Services (KLCAS)
http://www.klcas.org | 541-882-3500 | 535 Market Street, Klamath Falls, OR 97601
Community Services Consortium (CSC)
https://communityservices.us/rentrelief-application/ | 541-704-7506
250 Broadalbin St. SW, Suite 2A, Albany, OR 97321
Communities in Action (CinA)
https://www.communityinaction.info | 541-889-9555 | 915 SW 3rd Ave, Ontario, OR 97914
Community Action Program of East Central Oregon (CAPECO)
https://www.capeco-works.org/housing.html | 541-276-1926
721 SE 3rd St, Suite D, Pendleton, OR 97801
Mid-Willamette Valley Community Action Agency (MWVCAA)
https://mwvcaa.org/programs/the-arches-project/covid-rent-relief/ | 503-399-9080 - Dial 1
ARCHES Project, 615 Commercial Street NE, Salem OR 97301
Mid-Columbia Housing Authority (MCHA) | 500 E 2nd St. The Dalles, OR 97058
https://www.mid-columbiahousingauthority.org/covid-19-resources-2/| 541-296-5462
Community Action Program of East Central Oregon (CAPECO)
https://www.capeco-works.org/housing.html | 541-276-1926
721 SE 3rd St, Suite D, Pendleton, OR 97801
Mid-Columbia Housing Authority (MCHA) | 500 E 2nd St. The Dalles, OR 97058
https://www.mid-columbiahousingauthority.org/covid-19-resources-2/ | 541-296-5462
Community Action Program of East Central Oregon (CAPECO)
https://www.capeco-works.org/housing.html | 541-276-1926
721 SE 3rd St, Suite D, Pendleton, OR 97801
Yamhill
Yamhill Community Action Partnership (YCAP) | YCAP, P.O. Box 621, McMinnville, OR 97128
https://www.anydooryamhill.org | 503-687-1494
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Applicant's Name:
Self-Verification of Landlord/Tenant Relationship and Rent Owed
Rental Property Address:
Landlord's Name (name where rent is sent):
Landlord's Address:
Landlord's Phone:
Landlord's Email:
Landlord is the management company authorized to manage the property?
Yes No Unknown
Applicant Move-in Date:
Expiration of Tenancy (if any, not required):
Monthly Rent Payment:
Rent Past Due:
Are any utilities included in the rent payment? Yes No
If yes, please list:
I understand that I may need to provide additional information or answer additional questions because I am not able
to produce a written lease or a Verification of Landlord/Tenant Relationship and Rent Owed with a signature from
my landlord.
I certify that the information presented in this certification is true and accurate to the best of my knowledge. I
further understand that providing false representation constitutes an act of fraud. False, misleading, or incomplete
information may result in denial of the application, repayment of any funds received through the Oregon Emergency
Rental Assistance Program (OERAP), or other remedies available under law, including but not limited to liabilities and
penalties under the Oregon False Claims Act.
Signature of Applicant
Printed Name of Applicant Date
(if no written lease
AND landlord cannot or will not sign Verification of Landlord/Tenant Relationship)
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
VISIT, CLICK, AND APPLY TODAY!
25
Applicant's Name:
Verification of Landlord/Tenant Relationship and Rent Owed
Rental Property Address:
Landlord's Name (name where rent is sent):
Landlord's Address:
Landlord's Phone:
Landlord's Email:
Landlord is the management company authorized to manage the property?
Yes No Unknown
Applicant Move-in Date:
Expiration of Tenancy (if any, not required):
Monthly Rent Payment:
Rent Past Due:
Are any utilities included in the rent payment? Yes No
If yes, please list:
I certify that the information presented in this certification is true and accurate to the best of my knowledge. I
further understand that providing false representation constitutes an act of fraud. False, misleading, or incomplete
information may result in denial of the application, repayment of any funds received through the Oregon Emergency
Rental Assistance Program (OERAP), or other remedies available under law, including but not limited to liabilities and
penalties under the Oregon False Claims Act.
Signature of Applicant
Printed Name of Applicant Date
(if no written lease)
I certify that the information presented in this certification 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 denial of the application, repayment of any funds received through the OERAP, or other
remedies available under law, including but not limited to liabilities and penalties under the Oregon False Claims Act.
Signature of Landlord
Printed Name of Landlord Date
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
VISIT, CLICK, AND APPLY TODAY!
26
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OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM (OERAP) (Oregon)

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