855.827.3466 Facebook: @PHFA.org
www.PHFA.org Twitter: @PHFAtweets
REMINDER: ALL CARES RENT RELIEF PROGRAM APPLICATION AND SUPPORTING DOCUMENTS MUST BE
SUBMITTED DIRECTLY TO THEIR COUNTY’S DESIGNATED CARES RRP ORGANIZATION. PARTICIPATING
ORGANIZATIONS CAN BE FOUND ON THE PHFA WEBSITE AT HTTPS://WWW.PHFA.ORG/PACARES/.
HOUSEHOLD INFORMATION
Lessee(s) Name: ____________________________________________________________________
Lessee(s) Address: __________________________________________________________________
City, State, Zip: _____________________________________________________________________
County: ____________________________________________________________________________
Lease Eective Dates: _____________________________ to _______________________________
Phone Number: ___________________ Email (if available): _______________________________
Monthly Rent Amount: $_____________
Amount of Late/Missed Rent (rent due before March 1, 2020 is not eligible): $ ______________
List month(s) with late/missed rent payments between March 1, 2020, and December 30, 2020:
____________________________________________________________________________________
The following information is requested by the Federal Government for certain types of programs related to a dwelling
in order to monitor compliance with equal credit opportunity, and fair housing. You are not required to furnish this
information, but are encouraged to do so. If you furnish the information, please provide both ethnicity and race.
For race, you may check more than one designation.
Do you wish to provide this information? Yes _____ No ____
Sex: Male Female
Ethnicity: Hispanic or Latino Not Hispanic or Latino
Race: American Indian or Alaska Native Asian White
Black or African American Native Hawaiian or Other Pacific Islander
1. Are monthly rent payments split between more than one lessee?
Yes ____ No ____
2. Do you have either a written or oral lease agreement with your landlord?
Yes ____ No ____
CARES RENT RELIEF PROGRAM
LESSEE HOUSEHOLD CERTIFICATION/RENTER APPLICATION
855.827.3466 Facebook: @PHFA.org
www.PHFA.org Twitter: @PHFAtweets
3. Have you and/or your landlord provided a lease agreement (written) and included a third-party document that can
be used to verify residency for each lessee requesting CARES RRP assistance (i.e. utility bill, cancelled check with
address, pay stub or ID showing the current residence address)? Please include third-party supporting documentation
for both written and oral leases.
Yes ____ No ____
4. Do you attest that you either have or will continue to occupy that residence for every month which CARES RRP
assistance funds are being applied?
Yes ____ No ____
5. If yes, how are payments splits between lessees?
Lessee #1 Name: _______________________________ Amount of monthly Rent Paid by Lessee #1: $ _______________
Lessee #2 Name: _______________________________ Amount of monthly Rent Paid by Lessee #2: $ _______________
Lessee #3 Name: _______________________________ Amount of monthly Rent Paid by Lessee #3: $ _______________
Lessee #4 Name: _______________________________ Amount of monthly Rent Paid by Lessee #4: $ _______________
6. Did you become unemployed after March 1, 2020 as result of the COVID-19 pandemic?
Yes ____ No ____
7. What was the date of separation from your employer?
_________________________, 2020
8. Have your work hours or wages been reduced as a result of the COVID-19 pandemic?
Yes ____ No ____
9. Have you provided documentation for all sources of lessee income?
Yes ____ No ____
10. Are you able to provide documentation to verify unemployment with the Department of Labor and Industry’s
Bureau of Unemployment Compensation?
Yes ____ No ____
CARES RENT RELIEF PROGRAM
LESSEE HOUSEHOLD CERTIFICATION/RENTER APPLICATION LESSEE HOUSEHOLD CERTIFICATION/RENTER APPLICATION
855.827.3466 Facebook: @PHFA.org
www.PHFA.org Twitter: @PHFAtweets
By signing below, I acknowledge and understand that providing a written false statement which I do not believe to be
true to PHFA is a misdemeanor of the third degree and is punishable as perjury under Pennsylvania Title 18, Section 4904,
relating to unsworn falsification to authorities, and that in addition to any other penalty that may be imposed, a person
convicted under this section shall be sentenced to pay a fine of at least $1,000.
Lessee #1 Name (Print): __________________________________ Social Security Number: ________________
Lessee #1 Signature: ____________________________________ Date: ______________, 2020
Lessee #2 Name (Print): _________________________________ Social Security Number: ________________
Lessee #2 Signature: ____________________________________ Date: ______________, 2020
Lessee #3 Name (Print): _________________________________ Social Security Number: ________________
Lessee #3 Signature: ____________________________________ Date: ______________, 2020
Lessee #4 Name (Print): _________________________________ Social Security Number: ________________
Lessee #4 Signature: ____________________________________ Date: ______________, 2020
CARES RENT RELIEF PROGRAM ASSISTANCE NOTICE
If approved, lessees benefitting from CARES RRP Assistance funds will be released from any obligation to pay
any past due or future rent for the months which CARES assistance funds are being applied. Any displacement of
residents or eviction proceedings for other outstanding housing expenses will be waived for at least 60 days from the
date rent was due within the last month assistance was provided.
LESSEE HOUSEHOLD CERTIFICATION/RENTER APPLICATION
CARES RENT RELIEF PROGRAM
LESSEE HOUSEHOLD CERTIFICATION/RENTER APPLICATION
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome