Self Attestation (April 2021)
(To be completed by adult household members only, if appropriate.)
Household Name: __
Property Address:_________________________________________________________
City:______________________________________ State:__________ Zip:___________
I, ___________________
__________ hereby certify the following:
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my
knowledge. I further understand that providing false representations herein constitutes an act of fraud. I acknowledge the
information provided is being used for the specific purpose of determining eligibility to receive assistance through
the Emergency Rental Assistance Program (ERAP). If requested, I will fully cooperate with any request to provide documents
to verify the information provided within.
Signature of Applicant Printed Name of Applicant Date
Please include the contact information (name, phone number, email address, and or physical address) of previous employer if you are reporting you are no longer
employed, were furloughed, experienced a hardship or had a loss of hours during COVID19.