Fillable Rent and Utility Assistance Application

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Rent and Utility Assistance Application

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Rent and Utility Assistance – Application
Eligibility:
We need to determine if you qualify for Rent and Utility Assistance. Answer all the question on this application. We will be asking for details about your household,
income, landlord, rent and utilities along with supporting documentation. Submitting this application does not mean you will receive rental assistance. Once we have
verified your income, rent and household information, we will determine your eligibility. The information you provide will be used for determining your eligibility for
assistance under the Rent and Utility Assistance Program. We will not provide your information to third parties, except as needed to determine your eligibility for rent
relief.
1. Are you currently homeless or without housing and in need of rental assistance through the RUP rent Relief Program? Yes No
2. Are you renting your primary residence? Yes No
3. Are you receiving Section-8 or Rural Development rental assistance? Yes No
4. Are you currently living in public housing? Yes No
5. Has your household experienced a loss of income during the Pandemic due directly or indirectly to COVID-19? Yes No
(Total household income decrease could be due to a layoff, reduction in hours or loss of business.)
6. Has your household experienced a financial hardship during the Pandemic due directly or indirectly to COVID-19? Yes No
(A hardship includes any significant costs or other financial hardship incurred)
7. Do any of the following apply to you; past due utility bill, past due rent, eviction notice, living in a motel/hotel, temporarily staying with friends/family, or
currently homeless? Yes No
(This question is meant to determine if you are experiencing housing instability)
8. Do you or any member of your household qualify for unemployment? Yes No
(Does anyone in your household qualify for unemployment benefits?)
9. Number of People in your Household. ______________________
(The number of people in your household in includes all adults listed on your lease, all children living in the rental more than 50% of the time, and any foster children or adults. Do not
include live-in aides. Do not include unborn children.)
10. Current Total Monthly Gross Household Income _____________________
(Enter the total of all household income sources, including but not limited to: wages, business income, social security or pensions, interest on savings accounts, TANF (welfare),
unemployment benefits and any other periodic payments or gifts from any source.)
Contact Information:
Address:____________________________________________ Unit#:___________________City:______________Zip Code:_____________________
Name:________________________________Date of Birth: ___________Social Security Number/ITIN: ______________ Check if you don’t have a SSN/ITIN
Phone Type:_______________Phone Number:________________________________Email:________________________________________________
Demographics:
What is your Gender? ____________________ Are you currently unemployed? Yes No If yes, what is the date of unemployment? __________
Are you Disabled? Yes No Are you Hispanic or Latino: Yes No What is your Race:__________________
Have you served in the US Military? Yes No
Household Member Information:
We need to know about everyone living in the unit except live-in aides. This includes all adults listed on the lease or rental agreement, children living in the unit more
than 50% of the time and any foster children or adults living in the rental. Do not include unborn children.
Name
Date of Birth
Gender
Hispanic or Latino
Race
SSN/ITIN
Check here if no
SSN/ITIN
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Income Information:
Check this box if you receive public benefits from Medicaid/Medical, Women Infant and Children (WIC) Benefits, Supplemental Nutrition Assistance Program
(SNAP) Benefits, Temporary Assistance for Needy Families (TANF) Benefits, or School Nutrition Programs (SNP) Benefits. If this applies to you skip the income
section and begin completing the Rental information Section below.
Tell us about all sources of income for the household. All amounts should be monthly.
Household Member who receives this income
Source of Income
Gross Monthly Amount
(before taxes)
Rental Information:
Check here if you do not have this information because you are; living in a hotel/motel, temporarily living with friends/family, or are currently homeless. If this
applies to you skip to the Utility Information Section below.
# of Bedrooms(for efficiencies, studio, or single room occupancy units, enter zero): _______________Lease Start Date:____________Rent Amount: _____________
Amount of Past Due Rent(only enter past due amounts after 3/13/20): ___________# of Months Past Due(do not count months prior to 3/13/20):________________
Landlord Information:
Check here if you do not have this information because you are; living in a hotel/motel, temporarily living with friends/family, or are currently homeless. If this
applies to you skip to the Utility Information Section below.
Name: _______________________________________Email Address:___________________________Phone Number:_______________________________
Mailing Address:______________________________________________City:__________________State:__________________Zip Code:________________
Utility Information:
If you do not pay for utilities check here
Total Amount Due
Past Due Amount
Months Past due
Date of most
current bill
Required Documents:
Valid government photo ID (expired documents and utility bill with name and address are acceptable alternatives)
Provide a copy of your lease, rental agreement, or other evidence of your rental obligation.
If you have one, provide a copy of your most recent past-due rent statement.
If you have one, provide a copy of your eviction notice.
Income Verification (provide all that apply)
2020 Income Tax Returns
Last Three Paystubs or
Wage Statement from your
employer(s)
Public Benefit
Award/Recertification
Letter
Social Security/Disability/Veteran
Benefit Award Letter date within
120 days of application.
Pension Statement
Workers Compensation
Statement
Alimony and/or Child
Support payments
Annual income derived
from assets to which any
member of the family has
access
Last three military payments
Financial Aid Award
Letter showing amount in
excess of tuition
Unemployment
and/or Disability
Compensation
Statement(s)
If requesting Utility Assistance, provide current utility bills for Electricity, Gas, Water, or Fuel/Oil
Terms and Conditions:
I declare under penalty of perjury that the information in this application is true and correct. I understand that providing false representation is an act of fraud
and that fraud will be prosecuted to the fullest extent of the law and may disqualify me from assistance programs.
I further declare that:
1. My household does not have sufficient savings or liquid assists to pay the rent/utility bills
2. I, nor any other persons, in my household have applied or will apply for this or any other rental/utility assistance program.
I understand that during the application process the Housing Authority of the County of Kern may check third party sources to verify the information that I
provided. I authorize the Housing Authority of the County of Kern to verify all information provided to them in this application.
If eligible, I understand the housing Authority of the County of Kern may make payments to be applied to my rent/utilities, and that payments provided to me
or on my behalf, are not for any other use.
Date: ______________________________ Signature: _______________________________________________________________________
To submit your application, email this form and required documents to RUP@kernha.org. Should you have any questions about your application, or if you
need assistance completing this form, contact us at: 661-578-5339
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Rent and Utility Assistance Application

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Completed 2 January 2022

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