Fill - Free fillable - PROGRAM GUIDELINES COVID19 EMERGENCY RENTAL ASSISTANCE PROGRAM PDF form



12



COUNTYOFLOSANGELES

COVID‐19EmergencyRentalAssistanceHouseholdIncomeSelf‐CertificationForm

INSTRUCTIONS:

This isawrittenstatementdocumentingtheAnnualIncome,thenumberofbeneficiarymembersin

thefamilyorhousehold,andrelevantcharacteristicsofeachmemberforthepurposesofincomedetermination.

Tocompletethisstatement, fillintheblankfieldsbelowusinginformationfromtheattachedIndividualAnnualIncome

Self‐CertificationFormcompleteandsignedbyEACHHOUSEHOLDMEMBERAGE18OROLDERexceptfulltimestudents.



TheapplicantHeadofHousehold(s)mustthensignthisstatementtocertifythattheinformationiscompleteandaccurate

andthatsourcedocumentationwillbeprovideduponrequest.



Applicant:

Address: City:

Telephone: State: ZipCode:



HouseholdMemberIncomeInformation



Name: TotalAnnualIncome: HH CH DIS S≥18 <18 <15











 











 





 

HH=HeadofHousehold;CH=Co‐HeadofHousehold;DIS=Personwithdisabilities;S≥18=Fulltimestudentage18or

over;<18=Childundertheageof18years; <15=Minorundertheageof15years



Annualgrossincome(totalofallmembers)=$





Icertifythatthisinformationiscompleteandaccurate.Iagreetoprovide,uponrequest,documentationon

allincomesourcestotheCountyofLosAngelesEmergencyRentalAssistanceProgramAdministrator.



HEADOFHOUSEHOLD

Signature PrintedName Date

CO‐HEADOFHOUSEHOLD

Signature PrintedName Date

WARNING:TheinformationprovidedonthisformissubjecttoverificationbyHUDatanytime,andTitle18,Section



1001oftheU.S.Codestatesthatapersonisguiltyofafelonyandassistancecanbeterminatedforknowinglyand



willinglymakingafalseorfraudulentsta tementtoadepartmentoftheUnite dStatesGovernment.



13



INDIVIDUALANNUALINCOMESELF‐CERTIFICATION

HouseholdMember(PrintName):  _____________

INSTRUCTIONS:Tocompletethisstatement,fillintheblankfieldsbelowusinginformationfromtheattached

IndividualAnnualIncomeSelf‐CertificationFormcompleteandsignedbyEACHHOUSEHOLDMEMBERAGE18

OROLDERexceptfulltimestudents.The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.



Source of Income Annual Income in Dollars

Salary

Self‐EmployedProfits

SocialSecurity(SS)

SupplementalSecurityIncome(SSI)

SocialSecurityDisability(SSD)

California Work Opportunity and Responsibility for Kids

(CalWORKs)

TemporaryAssistanceforNeedyFamilies(TANF)

Pension

Alimony

ChildSupport

UnemploymentInsuranc e

InterestfromBankAccountsandCashFunds

RentalPropertyIncome

OtherIncomeNotShownAbove

Sources:

TotalGrossAnnualIncome:

CheckhereifyouareaHOUSEHOLDMEMBERAGE18OROLDERwithnoincomeandcertifybysigningbelow.

Icertifythatthisinformationiscompleteandaccurate.Iagreetoprovide,uponrequest,documentation

onallincomesourcestotheCountyofLosAngelesEmergencyRentalAssistanceProgramAdministrator.



Signature Printed Name Date

WARNING:TheinformationprovidedonthisformissubjecttoverificationbyHUDatanytime,andTitle18,Section



1001oftheU.S.Codestatesthatapersonisguiltyofafelonyandassistancecanbeterminatedforknowinglyand



willinglymakingafalseorfraudulentsta tementtoadepartmentoftheUnite dStatesGovernment.



Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

- PROGRAM GUIDELINES COVID19 EMERGENCY RENTAL ASSISTANCE PROGRAM

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank - PROGRAM GUIDELINES COVID19 EMERGENCY RENTAL ASSISTANCE PROGRAM Form

Related forms

Fillable - PROGRAM GUIDELINES COVID19 EMERGENCY RENTAL ASSISTANCE PROGRAM

Fill Online, Printable, Fillable, Blank - PROGRAM GUIDELINES COVID19 EMERGENCY RENTAL ASSISTANCE PROGRAM Form

Related forms

First 20 documents completely FREE!