TNHA - ERA Form

PROGRAM SUMMARY

The Emergency Rental Assistance Program provides up to 12 month’s arrears or future assistance in increments of 3 months to renters, landlords, and utility providers who have been affected by the pandemic and economic insecurity within TNHA's service area. ERAP also applies to renters looking to secure a lease in a new unit to regain housing stability.

ELIGIBILITY

In order to qualify for ERAP, applicants must meet all of the following requirements:

Household income at or below 80% of the area median income; and
Qualify for unemployment or has experienced a reduction in household income, incurred significant costs, or experienced a financial hardship due to COVID-19; and
Demonstrate a risk of experiencing homelessness or housing instability; and
Submission of a completed program application:
- Applicant and household information. Full name, date of birth, and social security numbers for all household members; mailing address and contact information.
- Release of Information – Signed and dated by each household member 18 years of age or older.
- Proof of Identification – Photo ID (Government or State issued) for all household members 18 years of age and older.
- Household Income Documentation – Includes, but not limited to, the last 30 days of paystubs, pension statement(s), social security award letter(s), unemployment(s), 2020 Tax Returns, and/or documentation of any other household income received by all household members 18 years of age or older.
- Household Asset Documentation - Most recent statements with balance information, deeds or other documentation for assets listed on the application.
- Landlord Documentation – Current lease agreement, current statements, and any late payment and/or eviction notices (if available).
- Utility and/or Energy Cost Documentation – Current utility bills and/or statements, fuel delivery receipts, late payment notices and/or disconnect notices.
- Household COVID-19 Impact Documentation – Includes, but is not limited to, a notice or email from your employer documenting a job loss, furlough, closure, reduction in hours, or other documentation that supports the impact your household has experienced due to COVID-19.

Primary Applicant Full Name *

First Name Last Name

Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Day Phone *

Evening Phone *

Email *

example@example.com

Date *

Date

Rental Unit Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Landlord Name *

First Name Last Name

Landlord Tax ID/SSN

Phone *

Do you rent your home? *

Yes No

Is this your primary residence? *

Yes No

Do you live in Public Housing or receive a Voucher? *

Yes No

To be eligible for ERAP, your household income must be at or below 80% of the area median income. Household income includes wages, tips, etc. for all members of your household. You may adjust your income to include the deduction permitted using the IRS 10-40 Adjusted Gross Income method.

What is your zip code? *

What was your 2020 annual household income? *

What is your current monthly household income? *

To be eligible for ERAP, you or members of your household must have experienced financial hardship due to the pandemic. At least one of the following hardship 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 the COVID-19 pandemic. Has directly or indirectly experienced financial hardship due to the COVID-19 pandemic. Has been or is currently unemployed.

To be eligible for ERAP, you or members of your household must demonstrate risk of homelessness or housing instability. At least one of the following statements must be true:

You or a member of your household (check all that apply): *

Has received a rental eviction notice. Has received past-due rent or utilities notice(s). Is at increased risk of exposure to COVID-19 due to overcrowding. Is unsafe due to past or potential intimate partner violence, sexual assault, or stalking. Is delaying the purchase of essential goods/services to pay rent or utilities (e.g. food, prescriptions, childcare, transportation, or equipment for remote work or school). Is relying on credit cards, payday lenders, 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 ERAP, assistance received must not be duplicated.

Have you received Emergency Rental Assistance? *

Yes No

If yes, How many months for rental arrears?

Future?

Paid to:

If yes, How many months for utility arrears?

Future?

Paid to:

Household Members

	Name	Relationship	Date of Birth	Social Security #	Employer
Self
Member 2
Member 3
Member 4
Member 5
Member 6
Member 7
Member 8
Member 9
Member 10

Signature of Applicant *

Clear

Signature of Spouse

Clear

Signature of additional adult

Clear

Signature of additional adult

Clear

Signature of additional adult

Clear

Signature of additional adult

Clear

IF YOU BELIEVE THAT YOU HAVE BEEN DISCRIMINATED AGAINST, OR HAVE QUESTIONS ABOUT THE LAWS ABOUT DISCRIMINATION, CONTACT THE ALASKA STATE COMMISSION FOR HUMAN RIGHTS, AT 1-800-478-4692, OR YOU MAY CONTACT THE FEDERAL OFFICE OF FAIR HOUSING AND EQUAL OPPORTUNITY AT 206-220-5170.

I, ________________________________, [type full name below] (“Applicant”) am applying for certain housing assistance services from Taġiuġmiullu Nunamiullu Housing Authority Emergency Rental Assistance Program. As part of my application for services, I am required to provide background information for the determination of my eligibility. I hereby authorize the following listed person or entity to provide any and all records or other information regarding me and my household, in whatever format, that the person or entity has in his, her or its possession to Taġiuġmiullu Nunamiullu Housing Authority Emergency Rental Assistance Program listed below.

Name of Landlord

First Name Last Name

Phone number of Landlord/Business

Please enter a valid phone number.

Name of Utility Provider

Phone number of utility provider

Please enter a valid phone number.

Name to whom information should be released

Address to whole information should be released

City, State, and Zip to whom information should be released

Phone number to whom information should be released

By my signature below, I certify and attest that I am voluntarily authorizing the release of any records or other information regarding me and my household that is in your possession to the TDHE/Tribal Housing Program named above. This release and authorization is ongoing until expressly revoked in writing by the undersigned.

Applicant Signature *

Clear

TNHA - Emergency Rental Assistance

PROGRAM SUMMARY

ELIGIBILITY

APPLICANT AUTHORIZATION FOR RELEASE OF AUTHORIZATION