Wisconsin Emergency Rental Assistance (WERA) Program
Income and Housing Attestation
Shaded area to be completed by WERA agency.
Eligible clients (i) qualified for unemployment benefits or (ii) experienced a reduction in income, incurred
significant costs, or experienced other financial hardship due directly or indirectly to COVID-19 that
threaten the household’s ability to pay the costs of the rental property when due.
I hereby certify that the information given is complete and accurate to the best of my knowledge. I I
I understand that I may be required to present records and documents to support the information
provided. I understand that inaccurate or incomplete information reported could cause my
rental/utility assistance benefit(s) to change. By typing my name in the ‘Applicant Signature’ field, I
indicate that I am the person named, and this entry is the legal equivalent of a manual/handwritten
signature. I further understand that I may print out the document and sign by hand.
Applicant Signature Date Signed
Applicant First and Last Name
Income Type impacted by COVID-19 and/or during the pandemic:
Please check why income was impacted by COVID-19 and/or during the pandemic:
Business Closed Seasonal Job Hours Cut Furlough Laid Off Schools Closed
Other (Please explain):
Self-Attestation: Please describe your situation.
Please acknowledge by checking the box, that you have been unable to pay rent/utilities and are at risk of
loosing your housing or facing eviction due to COVID related events.
Please acknowledge by checking the box, that you have been not receiving other federally funded
emergency rental assistance.
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signature
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