Fillable Virginia Rent and Mortgage Relief Program (RMRP)

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Virginia Rent and Mortgage Relief Program (RMRP)

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  • 40 check-boxes
  • 103 other fields

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Virginia Rent and Mortgage Relief Program (RMRP)
Tenant Application
Date of Application: Unique Identifier*:
Property Name:
Landlord/Property Owner (full legal name):
Authorized Agent completing application on Landlord’s Behalf (if applicable):
Contact Info for Landlord/Agent E-Mail: Phone:
*Unique Identifier must be established by the Authorized Agent in the following format – Property Initials, Tenant Initials, Unit #,
and Date of Application in the YYMMDD format.
OVERALL MINIMUM REQUIREMENTS
In order to receive financial assistance through the Virginia Rent and Mortgage Relief Program (RMRP),
households must meet the following minimum requirements:
The Tenant has a valid lease statement in their name.
The household has experienced a loss of income due to COVID-19/Coronavirus pandemic (Head of
household must complete the self-certification of loss of income below).
The household’s total rent is at or below 150% Fair Market Rent for unit size and location.
The household’s current
gross income is equal to or less than 80% Area Median Income for household size
and location (supporting documentation required).
HOUSEHOLD INFORMATION
Please enter the following information for the primary tenant:
Last name:
First name:
Address: Unit #:
City: State: Virginia Zip Code:
County/City:
Phone:
Email:
Occupant Name Age Monthly Income
Click to CLEAR FORM
Click to PRINT FORM
2
Virginia RMRP Tenant Application
Tenant’s Full Name: Unique Identifier:
Property Name and Unit #:
Occupant Name Age Monthly Income
*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.
**Adjusted for household size and jurisdiction. Income limits are available via the following link:
https://www.huduser.gov/portal/datasets/il.html.
SELF CERTIFICATION OF LOSS OF INCOME
The Tenant has experienced a loss of income due to 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
.
Total Household Monthly Gross Income*
(Must attach supporting documentation as identified on page 4)
$
Number of Individuals in Household
Ages 0-8
Ages 9-17
Ages 18-24
Ages 25-34
Household’s Income AMI**
At or Below 30% AMI
51-80% AMI
31-50% AMI
Over Income
Is Household at or below 80% AMI**?
Yes
No
Ages 35-44
Ages 45-54
Ages 55-64
Ages 65 & over
TOTAL
3
Virginia RMRP Tenant Application
Tenant’s Full Name: Unique Identifier:
Property Name and Unit #:
Please describe your los
s of income due to the Coronavirus pandemic including circumstance(s) resulting in loss of
income:
ZERO INCOME CERTIFICATION
If household reports zero income on pg. 2, complete the below certification. If not, write N/A:
I, (Tenant) verify that I, along with any other adult members of
my household who are on the lease, are unemployed and not receiving any income, benefits, or financial
assistance from any federal, state, or local agency and/or other private entity. I understand that false
statement(s) or information provided to my landlord for the purposes of rental assistance through the
RMRP could result in denial from the RMRP. I understand that failure to report income as stated above is
grounds for denial from the RMRP.
4
Virginia RMRP Tenant Application
Tenant’s Full Name: Unique Identifier:
Property Name and Unit #:
RENT/FUNDING INFORMATION
Rent includes fees and utilities that are charged to the tenant as part of the rent and listed within the lease
agreement.
*Rent may include late charges if such charges are set forth in the Lease and were permissible under the CARES
Act and applicable state law at the time they were incurred.
**Current month’s rent is determined based on the date in which the application and all documentation has been
verified. If verified after the 15th day of the month, RMRP funds may also be used for the upcoming month’s rent.
DEMOGRAPHIC INFORMATION
Please enter the following information for the primary tenant:
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 (check only one)
Hispanic or Latino
Non-Hispanic or Latino
Don't Know/Refused
SUPPORTING DOCUMENTS ATTACHED
Please check all that apply.
Lease
(specifically tenant’s information, rent amount, and signatures)
Tenant Ledger and Associated Fees
Income verification
Check stubs from employer
Letter from employer
Bank statement
Unemployment insurance statement
SSI/SSDI verification
Child support/alimony verification
Other:
Tenant’s Monthly Rent Amount
$
Number of Bedrooms in Rental Unit
Tenant’s Rent Amount is at/below 150% FMR
Yes
No
Month & Year Amount Month & Year Amount
TOTAL AMOUNT of Rent Needed and
Requested from RMRP
(Amount of Past Due Rent
Owed + Current Month’s Amount of Rent Due)
$
5
Virginia RMRP Tenant Application
Tenant’s Full Name: Unique Identifier:
Property Name and Unit #:
VIRGINIA RMRP LANDLORD AND TENANT HOUSEHOLD AGREEMENT
This agreement details the rights and responsibilities of both Landlord and Tenant under the Virginia Rent and
Mortgage Relief Program (RMRP). By accepting payment of rent relief, I hereby agree to the following:
Landlord Agreement
I, (Landlord), acknowledge and agree to the requirement that
I must not evict the renter for non-payment of rent associated with any of the months for which the rent
relief payment is made. Furthermore, I understand that RMRP funds cannot be used to pay past due
rent prior to April 1, 2020. I understand that if the renter owes past due rent prior to April 1, 2020, I must
work with the tenant to develop an appropriate payment plan. If the tenant cannot adhere to the
conditions within the payment plan, either the tenant or I, may return to the Rent and Mortgage Relief
Program to apply for further assistance, provided the tenant remains eligible and funds are still
available.
I certify that, as part of the intake and assessment of the household, I have attempted to assist the
household with identifying other resources that may be available to them to prevent or divert them from
eviction or foreclosure without using RMRP funding. This included a discussion of alternative resources
available to the household including savings, linkages to mainstream and natural supports, and light-
touch assistance.
Landlords will notify Tenant by email or mail of the amount of rent paid by RMRP and steps to take if
Tenant find they are unable to pay rent in the future.
Furthermore, I acknowledge and agree to reimburse RMRP funds if it is determined at a later date that I
or my Authorized Agent(s) (identified below) recorded inaccurate information contained in the Tenant
Application Packet that resulted in determining the Tenant eligible for RMRP financial assistance when
Tenant was actually ineligible for said assistance.
Furthermore, I shall hold harmless the Commonwealth of Virginia, DHCD, its grantees/agents (including
Virginia Housing) and employees from all claims and demands based upon or arising out of any action
by me, my employees, agents or contractors.
I shall maintain all contractual and household records for at a minimum of five years, and shall provide
access to such records by Virginia Housing as may be requested.
I confirm that, in processing tenant’s application, I have complied with all applicable fair housing laws,
including but not limited to, Virginia's Fair Housing Law which makes it illegal to discriminate in
residential housing on the basis of race, color, religion, national origin, sex, elderliness, familial status,
source of funds, sexual orientation, gender identity, status as a veteran, or disability.
Tenant Agreement
I, (Tenant), acknowledge and understand the terms of this
agreement and have provided true and accurate information. I have been given the opportunity to ask
questions and understand that I should seek legal counsel if Landlord is in breach of this agreement.
6
Virginia RMRP Tenant Application
Tenant’s Full Name: Unique Identifier:
Property Name and Unit #:
TENANT 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 federal, state or local
subsidy or financial assistance for rent during the same time period with the requested RMRP.
Print name of Tenant
Tenant signature Date
LANDLORD / AUTHORIZED AGENT CERTIFICATION AND SIGNATURE
I certify the information I have recorded in the application and all attachments is accurate and
complete based on the information provided by the Tenant in applying for RMRP.
If this Application is completed by an Authorized Agent on behalf of Landlord, Authorized Agent
hereby certifies that it is duly authorized to act on behalf of Landlord as its agent with respect to
this Application, including, but not limited to, the Landlord Agreement set forth above.
The Landlord / Authorized Agent’s agreement with the certifications, terms, and conditions set forth
herein is evidenced by the following signature.
Determination of eligibility completed by:
Print name of Landlord / Authorized Agent Landlord / Authorized Agent Signature
Date
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Completed 8 February 2021

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