State of Georgia Rental Assistance Program
Income Documentation Waiver Form
T
o be completed by adult household members (age 18 and up) who are unable to obtain or
produce income documentation. This form should be completed and uploaded were required.
Ful
l Name: _________________________________________ Date of Birth: _____/____/_______
Address: ___________________________________________ Apt No.__________
City/State/Zip: ________________________________________
Email Address: _____________________________ Contact Phone No. _________________
Check the box that applies to your current income circumstances:
☐ I hereby certify that I receive income that is verifiable, but I am unable to obtain
documentation of income for one of the following reasons (please provide a full
description below):
____ I suffer from a disability and require an accommodation.
____ Circumstances related to the pandemic prevent me from obtaining the required
documentation.
____ Lack of technological access prevents me from being able to obtain my records.
- O
R -
☐ I hereby certify that I have not yet filed taxes for 2020 AND (1) have zero income, or (2)
currently receive income that is not verifiable for the following reason:
____
No qualifying income
____ Not verifiable due to the impact of Covid-19. (Please describe below.)
____ Payment was received in Cash. (Please describe source of payment below.)
N
ote: In addition to this certification, you may provide a signed statement from a
caseworker, employer, or other professional, who has knowledge of your household’s
income status and how it qualifies your household for the GRA program.
If you do receive income, please complete the following:
I he
reby certify that I receive income in the amount of $__________________ from the following
sources:
____ Wages from employment (including commissions, tips, bonuses, fees, etc.).
____ Dividends from assets.
____ Social Security payments, annuities, insurance policies, retirement funds, pensions, or death
benefits.
____ Unemployment or disability payments.
____ Public assistance payments.
____ Periodic allowances such as alimony, child support, or gifts received from persons not living
in my household.
____ Sales from self-employed resources
____ Any other source not named above (Please identify: _____________________________)
For a household member who is not the applicant, use the same email address and
contact phone number as the applicant.
