Emergency Rental Assistance Program

This is a written statement that permits the documentation of eligibility for the program based on any ONE or MORE of the following criteria: Household Income Financial Impact (e.g., unemployment, reduction in income, significantly increased expenses, or other financial hardship) Housing Impact (e.g., risk of housing instability or homelessness) Residence (e.g., proof of residence at an eligible rental unit in the absence of a lease/rental/sublease agreement)

Carefully read each section and complete ONLY the applicable criteria sections for which you are unable to provide the required supporting documentation and thus needing to self-attest.

Once you have filled out the applicable criteria sections you must sign the certification at the end.

The completed and signed certification can be uploaded with your online application at dfs.wyo.gov/erap.

Please note that the use of self-certifications may delay the processing of your application, require additional information from you, or result in limitations to the amount of assistance available to you.

or feel welcome to call the If you have any questions about the documentation requirements, visit the program website at dfs.wyo.gov Contact Center at 1-877-WYO-ERAP between 9am and 6pm MT, Monday through Friday.

Household income is determined using one of the two following methods:

• 2020 ANNUAL INCOME: Sum of all your rental household members’ income for calendar year 2020 using the Adjusted Gross Income (AGI) as noted on your Internal Revenue Service (IRS) Form 1040 series for individual Federal annual income tax purposes;
• or RECENT ANNUAL INCOME: Sum of all your household members’ income in the last two months and multiplied by 6. If this method is used to determine income eligibility, applicants will need to recertify their income every 3 months for any award extensions applied for by the applicant.

Sources of income may include: salary, wage, tips, commissions, business income, interest, dividend, social security benefit, annuities, insurance, Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits, unemployment and disability compensation, worker's compensation and severance pay, and Welfare assistance payments.

Note: if you are using a written attestation to demonstrate your current rental obligation, assistance provided to you under the State of Wyoming Emergency Rental Assistance Program will be limited to the lesser of: 1) the monthly rent owed or 2) a monthly maximum of 100% of the greater of the Fair Market Rent or the Small Area Fair Market Rent for the area in which the applicant resides, as most recently determined by HUD and made available at https://www.huduser.gov/portal/datasets/fmr.html, and is limited to three (3) months total.

CERTIFICATION

I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. I agree to provide, upon request, additional information or documentation upon request to the Program Administrator.

WARNING: The information provided on this form is subject to verification by the Treasury Department at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.