State of Georgia Rental Assistance Program
Hardship due to COVID-19 - Tenant Attestation
I or a member of my household, as of ____/____/____, am experiencing financial difficulty due to the
COVID-19 pandemic.
My household is experiencing financial difficulty due to:
Qualification for unemployment benefits for at least one household member
forms in which assistance has been or will be provided, may result in termination of
At least one household member has experienced a reduction in household income,
incurred significant costs, or experienced financial hardship (please check applicable
reason(s) and include written attestation to describe the financial hardship):
Experienced a loss or reduction of income due to COVID-19.
Needing to take extended time off work due to COVID-19, either to:
Care for my child(ren) whose school is closed; or
Care for a family member who is sick with COVID-19.
Needing to take extended time off work because I have tested positive for COVID-
Excessive COVID-19 related healthcare related or other expenses.
Penalties, fees, and legal costs associated with rent or utility arears.
Payments for rent or utilities made by credit card to avoid homelessness or
housing instability.
Moving costs for households that moved to avoid homelessness or housing
Increased internet access and computer equipment costs needed to attend work
and/or school.
Alternate transportation for households unable to use public transportation during
the pandemic.
Purchase of personal protective equipment (PPE).
Please briefly describe the financial hardship experienced due to COVID-19, including the
name of the household member that is experiencing the hardship. (written description
from applicant/effected tenant is REQUIRED):
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.