Fillable (One application per household/unit) (Utah DRE)

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(One application per household/unit) (Utah DRE)

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  • 4 check-boxes
  • 35 other fields

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Utah Division of Real Estate (DRE) aims to protect the public and promote responsible business practices through education, licensure, and regulation of real estate, mortgage, and appraisal professionals

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DWS-HCD 1063
Rev. 04/2021
State of Utah
Department of Workforce Services
Housing and Community Development Division
TENANT APPLICATION FOR ASSISTANCE
(One application per household/unit)
Primary Tenant Applicant (must be listed on lease):
Tenant Address:
City, State, Zip Code:
Phone Number:
Email:
1. Monthly Gross Income:
$
(Provide documentation to your landlord)
Enter the most recent full month’s income for your household. (Include all income for all
household members that are 18 years or older, unless they are a full-time student.) See
https://jobs.utah.gov/covid19/eraincome.pdf for details on what income should be included or
excluded.
Instructions: Multiply your hourly wage by the average hours worked per week. Then multiply
that number by 52. Then divide that number by 12 to get your Gross Monthly
Income.
Example: Matt earns $8 per hour and works 20 hours per week. $8 x 20 = $160, $160 x 52
= $8320, $8320/12 = $693.33.
2. 2020 Annual Gross Income:
$
(Provide documentation to your landlord)
Enter the 2020 Annual Gross Income for your household. (Include all income for all household
members that are 18 years or older, unless they are a full-time student.)
Instructions: Add all income received by all household members for the year.
3. How many people permanently reside in your home?
4. Have one or more individuals within the household been financially impacted directly or indirectly
related to COVID-19 after March 12, 2020?
Please select all that apply:
Qualified for unemployment benefits
Experienced a reduction in household income
Incurred significant costs
Experienced other financial hardship
5. Can one or more individuals within your household demonstrate a risk of experiencing
homelessness or housing instability, which may include:
A. A past due utility or rent notice or eviction notice
B. Unsafe or unhealthy living conditions
C. Any other evidence of such risk, as determined by the eligible grantee
involved …………………………………………………………………………...
Yes No
If YES, please explain:
6. Are you receiving rent assistance from another organization that is paying
your rent in full? ………………………………………………………………………
Yes No
Please list all sources and phone numbers of rental or utility assistance your household is
currently receiving, if applicable:
7. DEMOGRAPHIC INFORMATION
Primary Tenant’s Full Name:
Age:
Sex:
Race/Ethnicity (check one)
White
Black / or African American
Asian
Native Hawaiian or Other Pacific Islander
Multi-Racial
Other
Hispanic/ Latino Ethnicity (check one) ……………………………...…...…….
Yes No
8. Is anyone in your household currently unemployed and have been
unemployed for more than 90 days due to loss of employment? ………………
Yes No
9. Do you have any outstanding utility or internet bills? ………………………....…
If Yes, please provide documentation to your landlord.
Yes No
10. Do you use internet to engage in distance learning, telework, telemedicine,
or obtain government services? …………………………………………..……….
Yes No
11. Are you related to your landlord? ……………………………………………..……
Yes No
APPLICATION CERTIFICATION:
I certify under criminal penalty under the law of Utah that the information I provided on this application
is true and correct. I understand that if any of the information is false or inaccurate, I may be
responsible to repay any funds received.
I understand the Department of Workforce Services conducts reviews of rental assistance, even after
payments have been made. These reviews are designed to determine the accuracy and quality of
eligibility decisions made, and the accuracy of payments made. Applicants and recipients of rental
assistance may be asked to cooperate with these reviews which may include requests for additional
information. By participating in this program, you are agreeing to provide complete and accurate
information requested as part of a quality control review. Information requested must be provided to
the Department within 10 days of the request.
By signing this document, I consent to the disclosure of my name, contact information, and account
information to my landlord, utility companies, or any organization that may be assisting with my rent
or utility payments for the purpose of determining my eligibility for benefits and services.
Tenant Signature:
/s/
Date:
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
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(One application per householdunit) (Utah DRE)

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Completed 8 June 2021

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