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COVID EMERGENCY RENTAL ASSISTANCE (CERA)
Tenant Application
CERA Tenant Application (03/24/21) Page 1 of 6
Submit completed application
with supporting documents to
your local HARA. A list by
county can be found online at
https://www.michigan.gov/docume
nts/mshda/CERA_Contact_List_7
17582_7.pdf
The COVID Emergency Rental Assistance (CERA) program is
designed to keep Michigan residents who fell behind on their rent
and/or utilities during COVID-19 in their homes.
Who is eligible?
You may be eligible for the COVID Emergency Rental Assistance
(CERA) program if you meet all the following conditions:
1. Have received a past-due rent or utility notice, notice to quit
or a court ordered summons, complaint or judgment for
unpaid rent after March 13, 2020
2. Have a gross household income below 80% area median
income (AMI), for the area
3. Have experienced an eligible COVID hardship since March
13, 2020.
4. A state ID (or other government issued ID) in the tenant’s
name (with supporting proof of residency if the address
does not match the unit)
5. A lease agreement in the tenant’s name (if a written lease
was completed)
For more information on eligibility, please see the COVID
Emergency Rental Assistance (CERA) program FAQ (online at
https://michigan.gov/cera
) or call your local Housing Assessment
and Resource Agency (HARA). A list by county can be found
online at
https://www.michigan.gov/documents/mshda/CERA_Contact_List_
717582_7.pdf
Please:
Print clearly.
Do NOT include original
documents (send photocopies).
Avoid Processing Delays:
Applications must:
• Be complete, signed and
dated.
• Include all supporting
documents as listed in the
attached checklist.
• Be submitted to your local
HARA.
Applications submitted without
required supporting documents
can be held for a maximum of 30
days.
Disclaimer: All applications submitted to MSHDA will be discarded.
All applications must be sent to your local HARA.
COVID Emergency Rental Assistance (CERA) Tenant Application
CERA Tenant Application (03/24/21) Page 2 of 6
1. Tenant Information
Full Name (Head of Household)
Date of Birth (mm/dd/yyyy)
Social Security Number
Female
Male
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Veteran
Yes
No
2. Household Information – List all other persons living with you.
Full Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Female
Male
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Yes
No
Relationship to Head of Household
Head of Household’s child
Head of Household’s spouse or partner
Head of Household’s other relation member (other relation to head of household)
Other: non-relation member
Full Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Female
Male
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Yes
No
Relationship to Head of Household
Head of Household’s child
Head of Household’s spouse or partner
Head of Household’s other relation member (other relation to head of household)
Other: non-relation member
Full Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Female
Male
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Yes
No
Relationship to Head of Household
Head of Household’s child
Head of Household’s spouse or partner
Head of Household’s other relation member (other relation to head of household)
Other: non-relation member
Clear Form
COVID Emergency Rental Assistance (CERA) Tenant Application
CERA Tenant Application (03/24/21) Page 3 of 6
Full Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Female
Male
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Yes
No
Relationship to Head of Household
Head of Household’s child
Head of Household’s spouse or partner
Head of Household’s other relation member (other relation to head of household)
Other: non-relation member
Full Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Female
Male
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Yes
No
Relationship to Head of Household
Head of Household’s child
Head of Household’s spouse or partner
Head of Household’s other relation member (other relation to head of household)
Other: non-relation member
Full Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Female
Male
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Yes
No
Relationship to Head of Household
Head of Household’s child
Head of Household’s spouse or partner
Head of Household’s other relation member (other relation to head of household)
Other: non-relation member
Full Name
Date of Birth (mm/dd/yyyy)
Social Security Number
Female
Male
Gender Non-Conforming
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Disabling Condition
Yes
No
Yes
No
Relationship to Head of Household
Head of Household’s child
Head of Household’s spouse or partner
Head of Household’s other relation member (other relation to head of household)
Other: non-relation member
*Complete additional pages as needed to respond for all household members
COVID Emergency Rental Assistance (CERA) Tenant Application
CERA Tenant Application (03/24/21) Page 4 of 6
3. Household (Contract Unit) Address
Address (number, street, and apt. or suite no.)
City
State
Zip Code
County
4. Mailing Address, if different than above
Address (number, street, and apt. or suite no.)
City
State
Zip Code
5. Contact Information
Phone Number
Contact name and number to leave messages
Email Address
6. COVID Hardship
Please check the box/es of the situations that apply to your household.
One or more individual in the household qualified for unemployment benefits, or
has experienced a reduction in household income, or
incurred significant costs, or
experienced other financial hardship due directly or indirectly to the COVID outbreak
none of the above
Are you at risk of homelessness or housing instability because of your past-due rent or eviction notice?
Yes
No
7. Household Income – Does your household have any income? No Yes → Total monthly household income $ ___________________
Does your household receive benefits from the Food Assistance Program (FAP)? No Yes
Please check all sources of income that your household received in the last 30 days (one month). ATTACH PROOF
Social Security benefits Disability benefits Employment/earned income
Supplemental Security Income (SSI) Self-employment income Worker’s Compensation
Pension/retirement benefits Unemployment Money from family/friends
Veteran’s benefits/Military allotments Child Support Other, please list:
Tribal payments (Energy Assistance/LIHEAP, tribal GA, casino/gambling profit sharing, land claims, etc.) ______________________________
Rental income or a land contract, mortgage, or other payment payable to a household member
Household Member Name*
Source of Income
(include employer name, if applicable)
Rate of Pay or
Payment Amount
Number of hours
worked per week
(if applicable)
Payment Basis
(hourly, weekly,
monthly, etc.)
*Complete additional pages as needed to respond for all household members
8. Rental Information
Number of Bedrooms in Unit
Move-in date
Tenant Rent amount
Date of Last Payment
Owner/Landlord Name
Number of Months in Arrears
COVID Emergency Rental Assistance (CERA) Tenant Application
CERA Tenant Application (03/24/21) Page 5 of 6
Are you past due or delinquent on your rent?
Yes
No
Amount past due or delinquent
Total late fees amount
Is your rent subsidized by another program such as the Housing Choice Voucher Program, Section 8, Project Based Voucher, Public Housing, etc.?
Yes
No
Has the Owner/Landlord filed for eviction?
Yes
No
9. Utility and Internet Information
Are you past due or delinquent on your utility payments?
Yes – Must complete applicable box/es below
No
Do you have home internet? If yes, would you like help paying your bill?
Yes – Must provide Internet bill/statement
No
Utility Type
Electricity
Utility Provider
Amount past due or delinquent
Tenant makes utility payment to
Owner/Landlord
Utility Provider
Utility Type
Gas/Propane/
Other Heat
Source
Utility Provider
Amount past due or delinquent
Tenant makes utility payment to
Owner/Landlord
Utility Provider
Utility Type
Water
Utility Provider
Amount past due or delinquent
Tenant makes utility payment to
Owner/Landlord
Utility Provider
Utility Type
Sewer
Utility Provider
Amount past due or delinquent
Tenant makes utility payment to
Owner/Landlord
Utility Provider
Utility Type
Trash*
Utility Provider
Amount past due or delinquent
Tenant makes utility payment to
Owner/Landlord
Utility Provider
*Trash arrears are allowed only if included with another utility bill
10. Tenant Certification
Initials
I understand that if funded, this application only resolves the issue of rent arrears and fees owed through the date of payment of rental
assistance, and that all other obligations of the Lease remain enforceable.
Initials
I understand that if I receive program funds directly because my landlord or utility/internet provider has opted-out of the program that I
will pay the landlord or utility provider the program funds within five business days of receipt.
11. Tenant Signature
I certify that, to the best of my knowledge and belief, all the information presented and attached to this application is true, correct, and complete in every
respect; fully discloses my household income from all sources; and accurately represents my/our current living circumstances. I understand providing
false statements or information is grounds for denial of program assistance and potential state or federal prosecution. I authorize MSHDA, and any of
its authorized representatives to verify the information provided in this application is true and correct. I also understand that additional information might
be required to move forward with this program and/or verify my eligibility for assistance.
Tenant Signature
Date
COVID Emergency Rental Assistance (CERA) Tenant Application
CERA Tenant Application (03/24/21) Page 6 of 6
Checklist
Before submitting this application for the COVID Emergency Rental Assistance (CERA) program, please
review the following to make sure that all required information is included with the application.
Copy of past-due rent notice, a notice to quit or a court ordered summons, complaint or judgement
Copy of a state ID (or other government issued ID) in the tenant’s name (with supporting proof of
residency if address does not match the unit)
Most current copy of lease agreement in tenant’s name (if a written lease was completed)
Provide all proof of earned and unearned income for household members that live at the property
and that are over the age of 18
• Household income/benefits (unemployment, SSI, etc.) for one month, OR
• Copy of submitted 2020 IRS form 1040 (first two pages)
• Food Assistance Program Notice of Case Action form (only applicable for households with 3 or
less people)
Copy of ALL utility statements showing amount past due, if applicable
Copy of Internet bill/statement, if applicable
COVID Emergency Rental Assistance (CERA) Owner/Landlord Application and required
documents (Owner/Landlord may also submit separately)
Supporting documentation for proof of COVID Hardship (only one hardship is necessary)
Type of COVID
Hardship
Best Documents to Show
Proof
Alternate Documents to Show
Proof
A member of my
household qualified for
unemployment after
March 13, 2020
Unemployment Monetary
Determination Letter OR
screen shots from
unemployment website
showing payments and
person's name
Signed letter from applicant stating
the time period they received
unemployment benefits
A member of my
household has had a
10% reduction in income
after March 13, 2020
Signed letter from applicant outlining your original hours and pay rate
and reduced hours and pay rate during the COVID outbreak
A member of my
household has incurred
significant costs (over
$500) after March 13,
2020
Signed letter from applicant stating what type and amounts of
increased expenses the household incurred during the COVID
outbreak
A member of my
household experienced
other financial hardship
(over $500) after March
13, 2020
Signed letter from applicant stating what type of financial hardship
they occurred during the COVID outbreak
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Completed 10 May 2021

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