Fillable SELF-CERTIFICATION OF ELIGIBILITY FOR CITY OF FRESNO COVID-19 (City of Fresno)

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SELF-CERTIFICATION OF ELIGIBILITY FOR CITY OF FRESNO COVID-19 (City of Fresno)

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The SELF-CERTIFICATION OF ELIGIBILITY FOR CITY OF FRESNO COVID-19 (City of Fresno) form is 17 pages long and contains:

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  • 60 check-boxes
  • 183 other fields

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File type: PDF

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Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
1
Sections I, II, III, IV & VIII (highlighted in blue) are to be completed by the Tenant. Sections V, VI & VII
(highlighted in yellow) are to be completed by the Landlord.
Section I. Applicant Identification
1. Applicant Name
(Full name, including middle initial)
2. Address
3. City, State, Zip Code
4. Email
5. Phone Number
6. Alternate Phone Number
7. Birth Date (MM/DD/YYYY)
8. Gender
☐
Male
☐ Female
☐ Decline to State
9. Ethnicity
☐
Not Hispanic or Latino
☐ Hispanic or Latino
☐ Decline to State
10. Race
☐
White
☐ Black or African American
☐ Native Hawaiian or other Pacific Islander
☐ American Indian or Alaskan Native
☐
Asian
☐ Multiple Categories
☐ Decline to State
11. Tribal Information (if applicable)
Section II. Family Information
Number of individuals in the household (Complete for all individuals residing in the home. Include children
18 and under)
Age
Birth Date (MM/DD/YYYY)
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
2
Section III. Family Income and Eligibility
1. Current Total Monthly Family Income $
Must provide most current verification of income in the form of a wage statement, interest statement,
unemployment compensation statement, most recent W-2, or a copy of Form 1040 as filed with the IRS for
the household. If monthly wage income verification is provided, it must be within two months prior to the
submission of the application for assistance and will be redetermined every three (3) months for the duration
of assistance.
2. Did one or more individuals in the household qualify for the following programs?
☐ Medi-Cal
☐ Women, Infants, and Children (WIC)
☐ Supplemental Nutrition Assistance Program (SNAP) known as CalFresh in CA
☐ Food Distribution Program on Indian Reservations (FDPIR)
☐ Temporary Assistance for Needy Families (TANF) known as CalWORKS in CA
☐ Subsidized housing (not including housing choice, project- based, or Section 8 vouchers) that required
income documentation as a condition of residency
• Indicate Program Name: __________________________________________________________
☐ OTHER: Any household income-based state or federally funded assistance program for low-income
persons or households
• Indicate Program Name: __________________________________________________________
☐ OTHER: Any locally operated assistance program for low-income persons or households that requires
household income verification and uses federal income limits
• Indicate Program Name: __________________________________________________________
Must provide most current verification f participation in the program in the form of a determination letter
from the government agency that verified the applicant’s household income made on or after January 1,
2020
3. Did one or more individuals in the household qualify for unemployment benefits,
experience a reduction in household income, incur significant costs (e.g., child home on
distance learning, increase in child care costs, incurred medical costs related to COVID-19,
increase in household expenses due to COVID-19), or experience other financial hardship
after March 13, 2020, related to the COVID-19 pandemic?
☐
Yes
☐ No
If answered yes, please complete the COVID-19 Impact Affidavit
4. Can one or more individuals in the household demonstrate a risk of experiencing
homelessness or housing instability due to COVID-19 related factors after March 13, 2020,
which may include a past due utility or rent notice or an eviction notice?
☐
Yes
☐ No
If answered yes, please explain which situation applies and explain how the above was related to COVID -19.
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
3
Section IV. Tenant Rental Obligation Information
1. What is your monthly rent payment?
Must provide most current detailed verification of amount due to landlord/owner/business.
2. How many months do you owe in back rent after April 1, 2020?
Must provide most current detailed verification of amount due to landlord/owner/business.
3. How much is currently due to your landlord/owner after April 1, 2020 to March 31, 2021?
Must provide most current detailed verification of amount due to landlord/owner/business.
4. How much is due for utilities, not already covered by rent after April 1, 2020 to March 31, 2021?
a.) Electricity
b.) Gas
c.) Internet
d.) Water
e.) Sewer
f.) Solid Waste
5. How much have you incurred in relocation fees?
6. How much have you incurred in late fees?
Must provide March statement and most current verification of amount due to landlord/owner/business. If
applicant is eligible, rental arears will be considered priority payment followed by other expenses as listed
above.
5. Have you received any COVID-19 federal, state, or local rental assistance since March 13,
2020? (e.g., Housing Rental Assistance)
☐
Yes
☐ No
If answered yes, please identify the source and amount of assistance received. Provide supporting
documentation of assistance received.
6. Do you currently receive any federal, state, or local rental assistance? (e.g., Housing
Choice Voucher or Project-Based Rental Assistance)
☐
Yes
☐ No
If answered yes, please identify the source and amount of assistance received. Provide supporting
documentation of assistance received.
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
4
Section V. Landlord Identification
1. Landlord/Owner/Business Name
2. Address
3. City, State, Zip Code
4. Email
5. Phone Number
6. Alternate Phone Number
7. Is the property registered under
any of the following categories?
☐
Federally Subsidized Residential
☐ None
☐
Mixed-Use
8. Property Management Company
9. Apartment Complex Name
Section VI. Landlord’s Confirmation of Tenant’s Rental Obligation Information
1. What is the tenant’s monthly rent payment?
Must provide most current detailed verification of amount due to landlord/owner/business.
2. What is the tenant’s total rent due after April 1, 2020 to March 31, 2021?
Must provide most current detailed verification of amount due to landlord/owner/business.
3. Do you agree to accept payment from the City of Fresno’s Emergency Rental Assistance Program on
behalf of tenant?
Yes, Landlord agrees to participate. Landlord receives 80% of unpaid rent and waives
20% of back rent.
No, Landlord does NOT agree to participate. Tenant receives 25% of unpaid rent.
Landlord cannot evict tenant if 25% of unpaid rent is received and tenant provides
monthly update on COVID impact toward making complete payment of owed rent.
☐
Yes
☐ No
If answered yes, proceed to Section VII. Skip Section VIII.
If answered no, proceed to Section VIII. Skip section VII.
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
5
Section VII. Landlord Payment Information – Only complete if Section VI, Question 3 was marked “Yes”
Payment accepted via
☐
ACH
☐ Check
If you answered ACH, provide completed W-9 form and complete the attached ACH form.
If you answered Check, provide completed W-9 form.
Please ensure VI. Landlord Identification matches the Landlord self-certification, ACH, and W-9 for prompt
payment.
Issue payment to:
Mailing Address
City, State, Zip Code
Phone Number
Alternate Phone Number
Section VIII. Tenant Payment Information – Only complete if Section VI, Question 3 was marked “No”
Payment accepted via
☐
ACH
☐ Check
If you answered ACH, complete the attached ACH form.If you answered Check, complete Section VIII.
Please ensure I. Applicant Identification matches the Tenant self-certification and VIII. Tenant Payment
Information for prompt payment.
Issue payment to:
Mailing Address
City, State, Zip Code
Phone Number
Alternate Phone Number
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
6
I understand that this self-certification is a requirement for my household, as identified in Section II. Family
Information, to receive Emergency Rental Assistance.
I hereby affirm that the information provided in the Emergency Rental Assistance application is true and
complete to the best of my knowledge. I understand that if I provide any false information or
misrepresentation during the application process it will be grounds for denying my application to the
Emergency Rental Assistance Program. I understand in submitting this application, I am not guaranteed
financial assistance from the City of Fresno’s Emergency Rental Assistance Program.
In addition, my signature acknowledges my understanding and consent to the release of the information and
supporting documents in this application to the City of Fresno Emergency Rental Assistance Program and its
affiliated Administrators. I also understand and consent to the release of this application pursuant to the
Public Records Act, to the extent required under California law.
Tenant Name
Signature
Date
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signature
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Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
1 PDF PW 14235s
I understand that this self-certification is a requirement for my entity, as identified in Section V. Landlord
Identification, to receive Emergency Rental Assistance.
I hereby affirm that the information provided herein is true and complete to the best of my knowledge. I
understand that providing false information will be grounds for denying this application. I understand this
application is not a guarantee of financial assistance from the City of Fresno’s Emergency Rental Assistance
Program. I agree not to increase Tenant’s rent or charge late fines during the state of emergency. I agree
that if I accepted a direct payment under the Program, such payment will be payment in full of the entire
rental debt owed by the tenant for the specified time period. In addition, I have also acknowledged in this
certification that I have released my tenant from any and all claims for nonpayment of rental debt owed for
the specified time period, including a claim for unlawful detainer pursuant to paragraph (2) and (3) of Section
1161 of the Code of Civil Procedure, against the tenant and the tenant’s household.
In addition, my signature acknowledges my understanding and consent to the release of the information and
supporting documents in this application to the City of Fresno Emergency Rental Assistance Program and its
affiliated Administrators. I also understand and consent to the release of this application pursuant to the
Public Records Act, to the extent required under California law.
Authorized Agent
Title
Company
Signature
Date
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
8
REQUIRED DOCUMENTATION
TENANT
ANY FORM OF IDENTIFICATION
COMPLETED ACH FORM (to accept direct deposit, only if landlord does not accept payment)
COMPLETED EMERGENCY RENTAL ASSISTANCE APPLICATION
FEDERAL, STATE, OR LOCAL RENTAL ASSISTANCE RECEIVED AFTER MARCH 13, 2020
RENT STATEMENT
RENTAL AGREEMENT
RENTAL LEDGER
LANDLORD
COMPLETED ACH FORM (if accepting direct deposit on behalf of tenant)
COMPLETED EMERGENCY RENTAL ASSISTANCE APPLICATION
RENT STATEMENT (if tenant is unable to provide)
RENTAL AGREEMENT (if tenant is unable to provide)
RENTAL LEDGER (if tenant is unable to provide)
W-9
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
9
SUPPORTING DOCUMENTATION – If applicable (at least one is needed)
TENANT
Annual Verification Method
2020 FORM 1040
COVID-19 IMPACT AFFIDAVIT
EMPLOYER STATEMENTS
INTEREST STATEMENTS
INTERNET BILLS FROM APRIL 2020 AND MOST CURRENT (late or unpaid)
RELOCATION FEES AFTER APRIL 2020
UNEMPLOYMENT COMPENSATION STATEMENTS
UTILITY BILLS FROM APRIL 2020 AND MOST CURRENT (late or unpaid)
WAGE STATEMENTS
Monthly Verification Method (will be redetermined every 3 months, if approved for additional funding)
COVID-19 IMPACT AFFIDAVIT
EMPLOYER STATEMENTS
INTEREST STATEMENTS
INTERNET BILLS FROM APRIL 2020 AND MOST CURRENT (late or unpaid)
PAYCHECK STUBS (must be within two months prior to APRIL 13, 2020 and application filing date)
RELOCATION FEES AFTER MARCH 2020
UNEMPLOYMENT COMPENSATION STATEMENTS
UTILITY BILLS FROM APRIL 2020 AND MOST CURRENT (late or unpaid)
WAGE STATEMENTS
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
10
Section II. Family Information – Continued
Number of individuals in the household (Complete for all individuals residing in the home. Include children
18 and under)
Age
Birth Date (MM/DD/YYYY)
Last Name:
Birth Date:
Filing Date:
SELF-CERTIFICATION OF ELIGIBILITY FOR
CITY OF FRESNO COVID-19 EMERGENCY RENTAL ASSISTANCE
11
ADDITIONAL INFORMATION TO SUPPORT CLAIM
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SELF-CERTIFICATION OF ELIGIBILITY FOR CITY OF FRESNO COVID-19 (City of Fresno)

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Completed 12 August 2021

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