Self-Certification of Assets
Emergency Rental Assistance Program
Income from Assets: Annual income includes income derived from assets to which household members have
access. Interest or dividends earned are counted as income even when the earnings are reinvested.
Assets Categories:
Checking, Savings, Mutual funds, Money Market Acct. Equity in Rental Property, Retirement and Pensions, 401(K),
Stocks, Bonds, Treasury Bills, Certificate of Deposit, Annuities, Revocable Trust, Mortgages or Deed of Trust, Whole
Life Insurance policy, Lump sum- inheritance, Lottery Winnings, Insurance Settlements, Personal property held as
an investment (e.g., antiques, gems, etc.)
Full Name: __________________________________________________________________
Address: ___________________________________________________ Apt No.__________
City/State/Zip: ________________________________________________________________
Check the box that applies to your current asset income circumstances.
☐ I hereby certify that I nor any other household members have assets over $5,000.
I attest that the above information is true, correct, and complete to the best of my knowledge. I understand that
submitting false, misleading, or incomplete information may result in termination of participation in the Program.
_____________________________________ ____________________
Signature Date
