STATE OF GEORGIA RENTAL ASSISTANCE PROGRAM
STATEMENT OF HOUSING INSTABILITY
My household, as of / / , is at risk of experiencing homelessness or housing
instability since the start of the COVID-19 pandemic on March 13, 2020.
My household is experiencing housing instability due to (please select all options that apply to
your household’s circumstances):
Receipt of a rental eviction notice.
Receipt due to past due utility or rent notice (s).
Experiencing a housing cost burden, e. g., my rent is greater than 40% of my income
Forgoing or delaying the purchase of food, prescription medications, childcare, or similar
essential necessities.
I acknowledge that falsification of documents or any material falsehoods or omissions in the
Application, including knowingly seeking duplicative benefits, is subject to state and federal
criminal penalties. I am particularly put on notice that 18 U.S.C. §1001 provides, among other
things, that whoever knowingly and willingly makes or uses a document or writing containing any
false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any
department or agency of the United States will be fined not more than $10,000 or imprisoned for
not more than five years, or both.
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Signature Date
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Signature of Person Helping Complete Form Date
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Printed Name of Person Helping Complete Form
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