Fillable Roommate Certification Virginia Rent Relief Program (Virginia Department of Motor Vehicles)

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Roommate Certification Virginia Rent Relief Program (Virginia Department of Motor Vehicles)

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The Roommate Certification Virginia Rent Relief Program (Virginia Department of Motor Vehicles) form is 2 pages long and contains:

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Virginia Department of Housing and Community Development | Partners for Better Communities
Main Street Centre | 600 East Main Street, Suite 300 Richmond, VA 23219
www.dhcd.virginia.gov | Phone (804) 371-7000 | Fax (804) 371-7090 | Virginia Relay 7-1-1
Roommate Certification
Virginia Rent Relief Program
I, ____________________ (applicant name), hereby attest under penalty of perjury that I am
currently residing at ______________________________ (physical property address) where I
have entered into an agreement with ________________________ (leaseholder or landlord
name) to pay a share of the monthly rent in the amount of $________, beginning
_____________ (month/day/year) until _______________ (month/day/year). Additionally, I
certify that my rental arrangement during this time period is best described as:
______ Roommate: The Rent Relief Program (RRP) defines roommate as an adult
applicant who has a written agreement with the landlord. The applicant may or may not have
dependent children and is not a family member of the other adult(s) listed on the lease.
As a Virginia Rent Relief Program (RRP) applicant, I certify that I meet the program’s criteria and
am unable to pay my monthly rent. Additionally, I certify that I have not received any other
form of federal, state, or local subsidy or financial assistance for rent during the same time
period with the requested RRP and that I will repay any RRP assistance determined to be
duplicative. I understand that any misrepresentation of information or failure to disclose
information requested on this form may disqualify me from participation in RRP, and may be
grounds for termination of assistance.
Virginia Department of Housing and Community Development | Partners for Better Communities
Main Street Centre | 600 East Main Street, Suite 300 Richmond, VA 23219
www.dhcd.virginia.gov | Phone (804) 371-7000 | Fax (804) 371-7090 | Virginia Relay 7-1-1
I understand that any misrepresentation of information or failure to disclose information
requested on this form may disqualify me from participation in RRP, and may be grounds for
termination of assistance. WARNING: It is unlawful to provide false information to the
government when applying for federal public or benefit programs per the Program Fraud Civil
Remedies Act of 1986, 31 U.S.C. §§ 3801-3812. I certify that the above information is true and
correct.
______________________________ ______________________________
Applicant Printed Name Applicant Signature
______________________________ ______________________________
Leaseholder Printed Name Leaseholder Signature
______________________________ ______________________________
Landlord Printed Name (if applicable) Landlord Signature (if applicable)
_____________
Date
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Roommate Certification Virginia Rent Relief Program (Virginia Department of Motor Vehicles)

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Completed 28 October 2021

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