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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/.
Lessee(s) Name: ____________________________________________________________________
Lessee(s) Address: __________________________________________________________________
City, State, Zip: _____________________________________________________________________
Lease Eective 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