Checklist of Need

EMERGENCY RENTAL ASSISTANCE PROGRAM (ERAP)

Written Checklist of Need

This is to attest that I, First Name Last Name , currently residing at

Address

Address (include apt. #)

Street Address Line 2

City

zip

If address does NOT match the address on the ID/drivers license copy you are providing, attach a utility bill that shows your address.

am providing the following proof of need in order to apply for (check one or both)

Rental AssistanceUtility Assistance

due to the fact that I have lost income as a result of the COVID-19 pandemic. My proof of this is attached as (check how you are proving income loss and then attach that documentation)

Unemployment benefit letter (copy is attached)Reduction in income as proved by letter from employer stating you were laid off and eligible to return OR paystubs proving reduction in income OR computation sheet for self-employment with attachments.

AND I am at risk of homelessness because (check and provide documentation)

I am past due on rent (provide copy of lease AND landlord certification AND W9 for landlord ORI am past due on a utility that is needed for housing (provide copy of past due bill ORI am living in unsafe conditions and need to move.

I also, hereby attest that I have NOT received assistance through other federal, state or local assistance programs for this same time period OR if I have, I will provide proof so that duplication of service is prevented.

Signed

Clear