Fillable PRE-SCREENING TENANT APPLICATION Please fill out the questions (City of Oakland)

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PRE-SCREENING TENANT APPLICATION Please fill out the questions (City of Oakland)

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TENANT APPLICATION
The Georgia Department of Community Affairs administers the State of Georgia Rental
Assistance Program (GRA). GRA helps renters with their past due rent and utilities. Payment will
be made directly to landlords and utility providers.
PRE-SCREENING
Please fill out the questions below: (* = required)
What is the zip code of this property?*:
Do you rent a home or apartment?*: Yes No
Is this lease purchase/rent to own?*: Yes No
Is this your primary residence?*: Yes No
What is the total number of people who reside in this household?*:
Was the 2020 annual household income below $49550?*: Yes No
Has one or more of the individuals in your household qualified for unemployment benefits?*:
Yes No
Are you or a member of your household experiencing risks of homelessness or housing
instability as a result of COVID-19?*:
Yes No
Check all that apply:
Has received a rental eviction notice.
Has received past due utility or rent notice(s).
Do you live in a unit assisted by another federally funded housing or rental assistance
program?*: Yes No
Does the landlord have a family relationship to anyone in the household?*: Yes No
Are you only requesting assistance for utilities, and NOT rent?*: Yes No
Do you need assistance completing the tenant portion of the application?*: Yes No
If Yes, Do you need assistance completing the tenant portion of the application due to:
Lack of internet access, inadequate internet access, or lack of computer access
Dispute with your landlord
Your landlord has indicated they will not submit an application
You have a disabling condition
APPLICANT INFORMATION
Please tell us about yourself in as much detail as possible. (* = required)
First Name*: Middle Name: Last Name*:
Address 1*:
Address 2:
City*: State*: Zip*:
Date of Birth*:
Social Security Number*:
Gender*: Male Female Other
Race*: American Indian/Alaska Native Asian Black/African American Native
Hawaiian/Other Pacific Islander White Prefer not to answer.
Ethnicity*: Hispanic or Latino Not Hispanic or Latino Prefer not to answer.
Phone Number*:
Email Address*:
APPLICANT INCOME
Please fill out the following*:
INCOME SOURCE*
INCOME AMOUNT*
FREQUENCY*
(Monthly/Annually)
(Income Source: Salary, Wages, TANF, SSI/SSDI, Commissions, Tips, Bonuses, Overtime, Unemployment/Disability,
Compensation, Worker’s Compensation, Alimony, Child Support, Regular gifts from people not residing in household)
LANDLORD INFORMATION
Please tell us about the landlord information. (* = required)
Name of Landlord of Residential Dwelling*:
Landlord Email Address*:
Landlord Phone Number*:
Landlord Address 1*:
Landlord Address 2:
City*: State*: Zip*:
HOUSEHOLD INFORMATION
List Each Household Member and complete all fields in table below.
HOUSEHOLD
MEMBER NAME*
RELATION TO HEAD
OF HOUSEHOLD*
GENDER*
DATE OF
BIRTH
RACE
ETHNICITY
IMPACTED BY
COVID 19?
(Y/N)
Relation to Head of Household*: Head, Spouse, Co-Head, Foster child/Foster adult, Other youth under
18, Full Time Student 18+, Live-in aide, Other adult
Race: American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Other Pacific
Islander, White, Prefer not to answer
Ethnicity: Hispanic or Latino, Not Hispanic or Latino, Prefer not to answer
FINANCIAL INFORMATION
Complete the table below for each of the household member:
HOUSEHOLD MEMBER
NAME*
INCOME SOURCE*
INCOME AMOUNT*
FREQUENCY*
(Monthly/Annually)
Amount of 2020 total annual income for applicant and all other adult household members?*
Have you or any member of your household served in the U.S. Military? Yes No
If yes, how many household members served:
Are one or more individuals within the household unemployed as of the date of application for
assistance, and have not been employed for at least the past 90 days (based on date
application)? Yes No
If Yes, Date Employment was lost (Note: Date of job loss and not unemployment benefits)
Has any person or program assisted in paying rent or utilities for your household for the period
assistance is requested? Yes No
If Yes, please fill out the following:
PERSON/PROGRAM NAME*
AMOUNT*
FREQUENCY*
(Monthly/Annually)
UTLILITIES OR RENT*
ASSISTANCE INFORMATION
Please tell us about yourself in as much detail as possible. (* = required)
Total Amount of Assistance Requested:
Are you being evicted*: Yes No
Requesting rent assistance?*: Yes No
If Yes, please fill out the following:
Monthly Rent Amount*:
Amount of past due rent*:
Total Amount of Assistance Requested*:
How many future rental payments are you requesting?*:
Months Missed*: Mar 2020 Jun 2020 Sep 2020 Dec 2020 Mar 2021 Jun
2021 Apr 2020 Jul 2020 Oct 2020 Jan 2021 Apr 2021 Jul 2021
May 2020 Aug 2020 Nov 2020 Feb 2021 May 2021 Aug 2021
SIGNATURE
State of Georgia Rental Assistance Program: Tenant Attestation
I hereby certify that:
I, and my household members identified in this application, have occupied the unit for which
I am seeking assistance as the household’s principal residence during the period of time for
which the rental or utility arrears assistance, if any, is requested and will occupy the unit as
my/our principal residence throughout the remaining months for which the assistance is
provided.
I/We attest that we are currently experiencing housing instability or risk of homelessness and
may be in need of future rental payments, in addition to the payment of our past due bills, in
order to stabilize our housing. We have provided the required documentation as verification.
To my/our knowledge, the Unit for which I am receiving assistance is not receiving Housing
Choice Voucher or Project-Based Rental Assistance or is not public housing and is not receiving
any other form of assistance for the same month or months of rent for which this assistance is
requested, such as tenant-based voucher assistance (such as Section 8), or project-based
assistance.
I/We will not seek to obtain rental or utility assistance in the future for the same months of
rental arrears, rent, utility arrears, or utilities covered by this assistance, and if I/we do receive
such assistance I will report it to Landlord and/or Utility Provider using the contact information in
my/our lease or utility bill statement, and to the State of Georgia Rental Assistance Program. I
understand that the case may be referred for criminal prosecution if duplicate funds were
knowingly applied for and accepted with no notice to the funding entity.
I/We will inform the State of Georgia Rental Assistance Program within ten calendar days if
evicted from the Unit, if disconnected from Utility services, or if I/we no longer occupy the Unit
as my/our principal residence during the period of assistance.
I/We have provided a current written lease as part of the application, or if I/we have not
provided a current written lease, I/we have provided a signed copy of the Landlord Payment
Agreement Form, and that the information I have provided in the Tenant Application regarding
the terms of my/our lease, rent amount, and/or utility arrears are true and accurate.
I/We understand that if determined to be ineligible, I/We can appeal the decision by
submitting a formal request to GaERASupport@dca.ga.gov. Information regarding the appeal’s
process can be found on the Georgia Rental Assistance website at the following web
address: https://georgiarentalassistance.ga.gov
I/We shall provide the U.S. Department of the Treasury, the U.S. Inspector General, the U.S.
General Accounting Office, the Georgia Department of Community Affairs, or any of their duly
authorized representatives, access to and the right to examine and copy records related to a
payment made as a result of this application. If provided funds directly, I/we agree to keep
records of payment to the Landlord for a minimum of seven (7) years unless a notice of a
monitoring, audit, or litigation has been provided. If such notice has been provided, I/we will
keep the records of payment to the Landlord until the matter has had a final disposition.
I/We have been provided a copy of this certification.
I/We may remain responsible for charges presented with my utility bill, such as district
assessments or other fees, that are presented separately from the charges for utility service and
my rent.
I acknowledge that submission of this application does not create a promise of payment of
rental assistance by the Georgia Rental Assistance program.
I/We attest that we have completed the Hardship Due to Covid-19 section of the
application certifying that we have either (1) qualified for unemployment compensation
or (2) experienced a reduction in household income, incurred significant costs, or
experienced financial hardship.
The information I/We have provided is true, accurate, and complete, and if requested, I
am able to provide documentation to prove my household’s loss of income or additional
expenses. I/We understand that providing false, incomplete, or inaccurate information on
application forms or seeking duplicate assistance for months in which assistance has
been or will be provided, may result in termination of participation in the Program, up to
5 years of imprisonment and for each occurrence a fine of up to $10,000.
Did anyone assist you in completing this application?*: Yes No
If yes, please list their name:
Print your name to sign*:
REQUIRED DOCUMENTS
Please include the following documents with this application and mail it to:
Georgia Dept. of Community Affairs
ATTN: Georgia Rental Assistance Program
60 Executive Park South, NE
Atlanta, GA 30329
Alternatively, you can fax your completed application and supporting documents to
404-393-8829
ü Income Verification for every adult household member*
ü Copy of Lease or Landlord Certification*
ü Eviction Notice, Past Due Rent, or Utility Notice
ü Proof of Identity
ü Additional Files (optional)
Required Documents for Tenants
What documents will a Tenant need to provide to complete the GRA Landlord Application?
Tenants will need the following types of documents/items (e.g., copies, pictures, screenshots,
etc.) along with their signed, fully completed application. The online application will specify the
actual documents required.
Proof of Identity
ü Driver’s license
ü Government-issued photo identification
ü U.S. Military photo ID
ü Tribal photo ID
ü Passport
Verification of Income
Annual Income Documentation
Acceptable supporting documentation for households seeking assistance based upon the
household's 2020 annual income:
ü Copy of Form 1040 for 2020 as filed with the IRS for the household (For Form 1040, both the
return and the tax forms used to establish the household's income for tax purposes, such as
W-2 statement(s) and any 1099 forms, must be submitted)
ü Documents evidencing annual income (e.g., wage statement, interest statement,
unemployment compensation statement)
ü Receipts of forms of benefit income, such as TANF, Social Security, SSI, and SSDI
payments that are not always considered taxable income and will not be reported on a tax
form
Monthly Income Documentation
If the applicant is seeking assistance based upon the current household monthly income, the
household must provide income verification for at least the most recent two months (60 days)
leading up to application submission, and eligibility must be redetermined every three months
for the duration of the assistance.
Acceptable supporting documentation for the monthly income option includes:
ü Documents evidencing monthly income (e.g., wage statement, interest statement,
unemployment compensation statement),
OR
In addition to the above, for the monthly income option, documentation for monthly income for
the two months leading up to application submission may also include:
ü If employed, pay stubs, third party verification from the employer, or a letter from their
employer indicating reduced pay
ü Documentation of cash assistance such as Social Security income, unemployment benefits,
worker's compensation (excluding lump sum distributions), or public assistance benefits
ü Documentation of child support, alimony
ü TANF, SSI or other supplemental income programs that are limited to households with
incomes below 80 percent of AMI (or a comparable poverty threshold)
ü Documentation of any income received for self-employment, including documentation of
income from the operation of a business or profession, or direct payments for services
ü Bank statements
ü Documentation of Social Security, annuities, retirement income, pensions, disability or death
benefits (to include spousal benefits) and other similar types of periodic or monthly receipts,
excluding benefits received by anyone 17 years old or under
Note:
Income that should NOT be included would include wages of children under the age of 18,
foster care income, adoption assistance, and income for a live-in aide. Earnings in excess of
$480 for each full-time student in the household unless they are the head of household or
spouse are also excluded.
If individual circumstances prevent applicant from providing requested documentation, DCA
reserves the right to evaluate waivers for certain documentation on a case-by-case basis
Verification of Renter Status
Tenant Applicants must submit:
ü Lease agreement that has been signed by both parties must be submitted in its entirety as
part of the initial application OR
ü Households without a current signed lease (such as those renting under a month-to-month
arrangement) should provide a certification that they still reside in the rental unit for which the
assistance is being applied and confirmation of this from their landlord.
ü Mobile homes are eligible for rent arrearages on the unit being rented.
Note:
Assistance under this program is not allowed for households residing in a hotel, motel,
temporary lodging, or a boarding house at this time. Lease-purchase and rent to own units are
ineligible for assistance in addition to housing cooperatives.
If individual circumstances prevent applicant from providing requested documentation, applicant
may provide evidence of paying utilities for the residential unit, an attestation by a landlord who
can be identified as the verified management agent the unit, or other reasonable documentation
as determined by DCA.
Verification of Risk of Experiencing Homelessness or Housing
Instability
The household must also be able to demonstrate a risk of experiencing homelessness or
housing instability to qualify. Acceptable documentation for this can include the following:
ü An eviction notice
ü A past due rent notice or
ü A past due utility notice
Acceptable documentation of rent and utility arrears may include the most recent past due bill,
an eviction notice, a PDF or screenshot of an online payment portal, or a letter or email from a
landlord to a tenant.
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PRE-SCREENING TENANT APPLICATION Please fill out the questions (City of Oakland)

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Completed 24 May 2021

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