Fillable SELF ATTESTATION FORM (Government of the District of Columbia)

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SELF ATTESTATION FORM (Government of the District of Columbia)

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The SELF ATTESTATION FORM (Government of the District of Columbia) form is 8 pages long and contains:

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  • 16 check-boxes
  • 66 other fields

Country of origin: US
File type: PDF

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SELF ATTESTATION FORM
IN
STRUCTIONS
This template allows for applicants to self-attest their eligibility for the STAY DC program based on any ONE or MORE of the following
required criteria:
Rental Obligation (e.g., proof of residence at an eligible rental unit in the absence of a lease/rental/sublease agreement)
Financial Impact (e.g., unemployment, reduction in income, significantly increased expenses, or other financial hardship)
Housing Impact (e.g., risk of housing instability or homelessness)
Income qualification (e.g., total household income at or below 80% AMI)
Carefully read each section and complete ONLY the applicable criteria sections for which you are unable to provide the required
supporting documentation or a written attestation from an applicable third-party and thus needing to self-attest.
NOTE: This is a fillable form and you can click directly on the boxes within each applicable section below to fill in your information
Once you have filled out the applicable criteria sections you must sign the certification at the end.
The completed and signed certification can be printed and attached to your paper application or uploaded with your online application
at stay.dc.gov
Per guidance from the US Treasury, the STAY DC program may perform additional testing or review processes to help minimize the
potential for fraud. The use of self-certifications may delay the processing of your application, require additional information from
you, or result in limitations to the amount of assistance available to you.
If you have any questions about the documentation requirements, visit the program website at stay.dc.gov or feel welcome to call the
Contact Center at 833-4-STAYDC (833-478-2932) between 7am and 7pm ET, Monday through Friday.
SELF-ATTESTATION OF RENTAL OBLIGATION
IF you cannot provide the required documentation of rental obligation at this time, please provide information about your rental housing
using this form. [IF you have this documentation and plan to provide it as part of your application, you can skip to the next section of the form.]
Please provide information about your rental unit and housing provider
Rental Unit Address
Address 2
City
State
Zip Code
Name of Housing Provider
Housing Provider Email
Address
Housing Provider Phone
Number
Date Rental Arrangement
Began (optional)
Date Rental Agreement is
Scheduled to end (optional)
Does Monthly Rent Include Utilities? Yes No
If yes, how much of monthly payments to housing provider is related to utilities?
Note: if you are using a written attestation to demonstrate your current rental obligation, assistance provided to you under the STAY DC
program will be limited to a monthly maximum of 100% of the greater of the Fair Market Rent or the Small Area Fair Market Rent for the
area in which the applicant resides, as most recently determined by HUD and made available at
https://www.huduser.gov/portal/datasets/fmr.html.
Further, assistance provided based on written self-attestation of the rental payment amount is limited to three (3) months total.
SELF-ATTESTATION OF FINANCIAL IMPACT QUALIFICATION
IF you cannot provide the required documentation of financial impact at this time, please explain how you or one or more individuals within
the household has qualified for unemployment benefits or experienced a reduction in household income, incurred significant costs, or
experienced other financial hardship due, directly or indirectly, to the COVID-19 outbreak. [IF you have the required documentation and plan
to include it with your application, you can skip to the next section of the form.]
SELF-ATTESTATION OF RISK OF HOUSING INSTABILITY OR HOMELESSNESS
IF you cannot provide the required documentation of risk of housing instability or homelessness at this time, please explain how you or one
or more individuals within the household is at risk of housing instability or homelessness. [IF you have the required documentation and plan
to include it with your application, you can skip to the next section of the form.]
P
lease explain how you or one or more individuals within the household is currently at risk of experiencing homelessness or housing
instability (this is demonstrable through past due utility or rent notice or eviction notice or unsafe or unhealthy living conditions)
SELF-ATTESTATION FOR HOUSEHOLD INCOME QUALIFICATION
IF you cannot provide the required documentation of income at this time, or you believe your income is categorically eligible as described
below, please use this form to document your income. [IF you have the required documentation and plan to provide it as part of your
application, you can skip to the signature page.]
C
ategorical Eligibility
Please indicate if your household income has been certified as eligible on or after January 1, 2020 due to your enrollment in ONE or more of
the following District or Federal programs:
Tenant-based Housing Choice Voucher
Project-based Housing Choice Voucher
Public Housing
Low Income Housing Tax Credit
DC Housing Production Trust Fund
National Housing Trust Fund
Home Investment Partnerships (HOME)
Inclusionary Zoning
Veterans Affairs Supportive Housing (VASH) Voucher
Rapid Rehousing
Project Based HCV COVID-19 Housing Assistance Program (CHAP)
Tenant-Based Rental Assistant (TBRA)
Housing Stabilization Grant (HSG)
DC Emergency Rental Assistance Program (Local)
Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
Household Income Attestation
IF you cannot provide the required documentation and do NOT qualify for any of the above programs at this time, please use this form to
document your income. [IF you have the required documentation and plan to provide it as part of your application, you can skip to the
signature page.]
FULL NAME (including YOURS)
YOU (Indicate
“self” for your
EMPLOYED?
(Y or N)
Annual GROSS
INCOME
Annual gross income from all sources (total of all members)
H
ousehold income is determined using one of the two following methods:
2020 ANNUAL INCOME: Sum of all your rental household members’ income for calendar year 2020 using the Adjusted Gross Income
(AGI) as noted on your Internal Revenue Service (IRS) Form 1040 series for individual Federal annual income tax purposes; or
RECENT ANNUAL INCOME: Sum of all your household members’ income in the last two months and multiplied by 6. If this method is
used to determine income eligibility, applicants will need to recertify their income every 3 months for any award extensions applied f
or
by t
he applicant.
P
otential sources of income may include: salary, wage, tips, commissions, business income, interest, dividend, social security benefit, annuities,
insurance, Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits, unemployment and disability
compensation, worker's compensation and severance pay, and Welfare assistance payments.
Attestation of lack of income documentation
Please detail the circumstances that do not permit you to provide the required supporting documents necessary to complete an income
eligibility review:
CERTIFICATION
I
declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct.
I agree to provide, upon request, additional information or documentation upon request to the STAY DC Program Administrator.
A
pplicant Signature: _________________________________________
Da
te: _________________________________________
WARNING: The information provided on this form is subject to verification by the Treasury Department at any time, and Title 18,
Section
1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and
willingly making a false or fraudulent statement to a department of the United States Government.
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SELF ATTESTATION FORM (Government of the District of Columbia)

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Completed 16 June 2021

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