Fillable Virginia Rent and Mortgage Relief Program (RMRP)

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Virginia Rent and Mortgage Relief Program (RMRP)

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The Virginia Rent and Mortgage Relief Program (RMRP) form is 3 pages long and contains:

  • 3 signatures
  • 38 check-boxes
  • 46 other fields

Country of origin: OTHERS
File type: PDF

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8/24/2020
Virginia Rent and Mortgage Relief Program (RMRP)
TENANT/HOMEOWNER APPLICATION
Date of Application: Unique Identifier:
Property Name (if applicable):
HOUSEHOLD INFORMATION
Please enter the following information for the primary tenant/homeowner:
Last name: First name:
Address: __________________ Unit #: ________________________
City: State: Virginia Zip Code:
County/City:
Phone: Email:
Total Household Monthly Gross Income
(Must attach supporting documentation as identified on
page 3)
$
Number of Individuals in Household
Ages 0-8
Ages 9-17
Ages 18-24
Ages 25-34
Ages 35-44
Household’s Income AMI
At or Below 30% AMI 31-50% AMI
51-80% AMI Over Income
Is Household at or below 80% AMI?
Yes No
The determination of income includes any unemployment insurance received by a member of
the household but does not include one-time payments such as a stimulus check. Income limits
are available via the following link: https://www.huduser.gov/portal/datasets/il.html.
The Tenant/Homeowner has experienced a loss of income due to the COVID-19/Coronavirus
pandemic. Please select the reason(s) for loss of income below:
Laid off
Place of employment has closed
Reduction in hours of work
Must stay home to care for children due to closure of day care and/or school
Reduction or elimination of child or spousal support
Not able to work and/or missed hours due to contracting COVID-19
Unable to find work due to COVID-19
Unwilling or unable to participate in their previous employment due to their high
risk of severe illness from COVID-19
Other – describe_______________________________________________________
Ages 35-44
Ages 45-54
Ages 55-64
Ages 65 & over
TOTAL
8/24/2020
RENT/FUNDING – MORTGAGE/FUNDING INFORMATION
RMRP payment for rent includes fees and utilities that are charged to the tenant as part of the
rent and listed within the lease agreement. RMRP payment for mortgage excludes property
taxes and homeowners insurance.
Tenant’s Monthly Rent/Homeowner’s Mortgage
Monthly Payment Amount
$
Number of Bedrooms in Rental Unit
Tenant’s Rent/Homeowner’s Mortgage
Payment Amount is at/below 150% FMR
Yes No
Amount of Past Due Rent/Mortgage Owed
(Enter the amount of past rent/mortgage due for
each month and indicate total amount in bottom
right)
April September
May October
June November
July December
August
TOTAL
Current Month’s Amount of Rent/Mortgage
Due
$
TOTAL AMOUNT of Rent/Mortgage Needed and
Requested from RMRP
(Amount of Past Due Rent/Mortgage Owed + Current
Month’s Amount of Rent/Mortgage Due)
$
DEMOGRAPHIC INFORMATION
Please enter the following information for the primary tenant/homeowner:
Race (check only one)
Multi-Racial
American-Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Don't know/refused
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Don't know/refused
8/24/2020
SUPPORTING DOCUMENTS ATTACHED
Please check all that apply.
Lease (only the pages of the current lease that specify the tenant’s information, rent
amount, and all signatures)
Tenant Ledger and Associated Fees
Income verification – check the document(s) attached:
Check stubs from employer
Letter from employer
Bank statement
Unemployment insurance statement
SSI/SSDI verification
Child support/alimony verification
Zero Income Certification form
Other: ______________________________
Attachment B: Virginia RMRP Household Eligibility Certification Form
Attachment C: Virginia RMRP Landlord and Tenant Household Agreement
TENA
NT/HOMEOWNER CERTIFICATION
I certify that the information I have provided in applying for RMRP assistance is true, accurate, and
complete. Additionally, I certify that I have not received any other form of subsidy, financial assistance
for rent during the same time period with CARES Act, or other federal, state, or local funding.
_______________________________ _____________________________ ____________
Print name of Tenant/Homeowner Tenant/Homeowner signature Date
(If applicable) I further certify that the third party identified below has my consent to sign RMRP
documents on my behalf:
Print name of authorized representative Authorized representative signature
Determination of eligibility completed by:
_______________________________ _____________________________ ___________
Print name of Staff Person Staff Person’s Signature Date
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Virginia Rent and Mortgage Relief Program (RMRP)

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Completed 23 December 2020

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