IRHA - Emergency Rental Assistance Recertification

IRHA's ERA Program Recertification
Eligibility:
1. Qualifies for unemployment or has experienced a reduction in household income, incurred significant costs, or experienced a financial hardship due to COVID-19.
2. Demonstrates a risk of experiencing homelessness or housing instability; and
3. Has a household income at or below 80 percent of the area median.
To be eligible, you or members of your household must demonstrate risk of homelessness instability. At least one of the following statements must be true: You or member of your household (check all that apply): *

Has received a rental eviction notice. Has received past due rent or utility notice(s). Is at increased risk of exposure to COVID-19 due to overcrowding. Is unsafe due to past or potential intimate partner violence or sexual assault or stalking. Is delaying the purchase of essential good/services to pay rent or utilities (e.g., food or prescriptions - child care or transportation - equipment for remote work or school). Is relying on credit cards or payday lenders or other high-cost debt products to pay for rent or utilities - or depleting savings rather than using wages or other income.
To be eligible for IRHA’s ERA Program, you or member of your household must meet certain criteria. At least one of the following statements must be true: You or a member of your household (check all that apply): *

Has qualified for unemployment benefits. Note that it is not necessary to be actively receiving benefits, only to have qualified for them. Has lost income due to the COVID-19 pandemic. Has incurred significant costs due to COVID-19 pandemic. Has directly or indirectly experienced financial hardship due to the COVID-19 pandemic. Has been or is currently unemployed.
Have you received assistance for rent and/or utilities from any other source? *

Yes No
If so, please explain
Primary Applicant Full Name *

First Name Last Name
Gender, Race and Ethnicity of primary applicant: *

Alaska Native American Indian Other
Address of Rental Unit: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address (if different):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security Number *
Home Phone *
Email *
example@example.com
How many people in Household? *
Household income: Tell us about your income. Applicants must provide this information to the best of their ability: *
Are you currently receiving unemployment? *

Yes No
When did you qualify for unemployment?

Month Day Year
Date
Date Employment Lost

Month Day Year
Date
Date employment resumed (If applicable)

Month Day Year
Date
Assistance with Utilities

Please provide the amounts of each utility you are currently paying.
Electric *
Gas *
Water & Sewer *
Trash *
Heating costs *
Which bills are past due, and how much? *
Utilities paid by landlord? *
Utilities paid by landlord:

Electric Gas Water& Sewer Trash Heating Costs
Assistance with Rent

Qualified applicants can receive assistance for up to 12 months of past or future rent. Past-due rent must be caught up first, and payments cannot be made for rent prior to March 12, 2020.
Past due rent amount *
Monthly rent amount *
Do you need assistance with future rent? *
Please provide a copy of your photo ID for identity verification and provide supporting documentation for your income. This information must be provided for your application to be complete. Please, attach copies of your utility bills, lease agreement, unemployment verification, and your landlord's phone number below.

Supporting documents can be one of the following: Recent paystubs, IRS form 1040, W2, or 1099, 2020 federal tax return, and bank statements.
Photo ID *

Cancel of
Utility Bill - Must include the address and name of who the utilities are in *

Cancel of
Lease/Rental Agreement *

Cancel of
Income Verification *

Cancel of
Landlords w-9 *

Cancel of
Attachment and a statement of the past due rent or eviction notice from the landlord *

Cancel of
Landlord's Phone Number *
You cannot duplicate any other federally funded rental assistance provided to such household. Please, initial below. *

Clear
By signing this application, you certify all these answers are true. Misleading or fraudulent statements can lead up to paying back all monies. If approved, rent and/or utility relief payments will be made directly to your landlords and utility companies.
Applicant Signature *

Clear
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
Full Name *

First Name Last Name
I request and authorize the Interior Regional Housing Authority to obtain any and all information to determine my eligibility for Emergency Rental Assistance Application. For example: Bank financial information, Cash Assistance of any kind (ASAP/ GA/ SSI/ SSDI/ APA), wage information, State of Alaska, DOL Unemployment, and any other information the Housing Authority needs for Eligibility purposes, and data collection for the funding source; The Department of Treasury. Please release my confidential information from my file to:

NAME: HOUSING DEPARTMENT PERSONNEL

ORGANIZATION: INTERIOR REGIONAL HOUSING AUTHORITY

ADDRESS: 828 27th Avenue, Fairbanks, AK 99701

Purpose of disclosure: Eligibility Determination for ERA

Material to be released: ANY

My signature indicates I have read this form and/or have had it read to me. I know that any and all information is to be disclosed for determining my eligibility.
This consent form does not expire unless revoked by me in writing. I am able to revoke this consent (in writing) at any time.
Applicant's Full Name *

First Name Last Name
Applicant's Signature *

Clear
Should be Empty:

IRHA's ERA Program Recertification

Assistance with Utilities

Assistance with Rent

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION