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Application for Emergency Rental Assistance

Who’s applying? Tenant Landlord (on behalf of tenant) Tenant Information

Last Name First Name SSN#

Address City Zip County

Phone Email Address Date

Household: Number of Adults Number of Children under 18 Has anyone in your household experienced financial hardship which may include, but not limited to, a period of unemployment, a decrease in household income or had increased household costs? Yes No If Yes, was this financial hardship due, directly or indirectly, to COVID–19? Yes No Is anyone in your household at risk of homelessness or housing instability? Yes No Has anyone in the household received federally funded rental assistance in the past 12 months? Yes No Are you a veteran? Yes No Has anyone been a victim of domestic violence? Yes No Citizenship: US Citizen Permanent Resident Temporary Resident Refugee Other Race (check all that apply): American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Other

Ethnicity: Hispanic Non-Hispanic Gender: Male Female Landlord or Property Manager Information

Property Management Company (if applicable)

Last Name First Name Tax ID# or SSN#

Address City Zip

Phone Email Address

Tenant Utility Information

Company Name Address (Street, City, Zip) Phone Account # 2 PA 600 ERA 2/21

Tenant Household Income

Please tell us about the income of any individual in your household who is 18 or over. Does anyone in your household have any income? Yes No If yes, check all that apply, and list the income you have already received. Commissions

Dividends

Gambling/Lottery

Guardian Fees

Money Earned from Babysitting

Money for Training

Money Paid to You for Loans

Money Paid to You for Rent

Money Paid to You for Room or Board

Pensions

Self-Employment

Sick Benefits

Social Security

Supplemental Security Income (SSI)

Support

Unemployment

Union Pay

Veteran Benefit

Wages from Employment

Workers Compensation

Other:

Name of Person with Income Type/Source of Income/Name of Employer Income/Pay: How Much?

How Often

Paid

Date of Most

Recent Payment

Tenant Household Expenses

Rent

Electric

Gas

Oil

Propane

Coal/Wood/Other

Trash

Water/Sewer

Monthly $

Monthly $

Monthly $

Monthly $

Monthly $

Monthly $

Monthly $

Monthly $

Arrears $

Arrears $

Arrears $

Arrears $

Arrears $

Arrears $

Arrears $

Arrears $

Notes:

ERAP Agency Use Only

Authorization Information: Approved Denied Date: Type(s) of Assistance Provided:

Rental Assistance Rental Arrears Housing Stability Services Utility Assistance Utility Arrears Amount of Assistance:

Rental Assistance $ Rental Arrears $ Housing Stability $ Utility Assistance $ Utility Arrears $ Total $ Number of months covered with: Rental Assistance Utility Assistance Household Income Level:

Does not exceed 30 percent of the area median income for the household Exceeds 30 percent but does not exceed 50 percent of the area median income for the household Exceeds 50 percent but does not exceed 80 percent of area median income for the household Notes: Used 2020 annual calculation for eligibility Used monthly income at time of application 3 PA 600 ERA 2/21

Rights and Responsibilities

RIGHT TO NONDISCRIMINATION

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or political beliefs.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Additionally, program information may be made available in languages other than English. To file a complaint of discrimination regarding a program receiving federal financial assistance through the U.S. Department of Health and Human Services (HHS):

(1) mail: U.S. Department of Health and Human Services (HHS) HHS Director, Office for Civil Rights, Room 515-F

200 Independence Avenue, S.W.

Washington, D.C. 20201; or

(2) call: 202-***-**** (voice) or 800-***-**** (TTY). This institution is an equal opportunity provider. RIGHT TO CONFIDENTIALITY

We will keep your information private. It will only be used to decide which programs you may be eligible

for. Any person knowingly violating any of the rules and regulations of this department shall be guilty of a misdemeanor and, upon conviction shall be sentenced to pay a fine, not exceeding one hundred ($100) dollars, or to undergo imprisonment, not exceeding six months, or both (62 P.S. section 483).

RESPONSIBILITY TO PROVIDE INFORMATION

You must give true, correct and complete information. You must help in proving the information, you give. Benefits may be denied if you fail to provide certain proof. If you are contacted by Department of Human Services

(DHS) or the Office of State Inspector General, you must fully cooperate with those persons or investigators. PRIVACY ACT STATEMENT

The collection of this information, including the Social Security number (SSN) of each household member, is authorized under 42 U.S.C. § 405(c)(2)(C)(i-iv) and 62 P.S. § 432.2(b)(3).

The information will be used to determine whether

your household is eligible or continues to be eligible to participate in the Emergency Rental Assistance

Program. We will verify this information through

computer matching programs. This information will

also be used to monitor compliance with program

regulations and for program management.

This information may be disclosed to other federal and state agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. Failure to provide an SSN may result in the denial of Emergency Rental Assistance to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members. If someone wants help getting an SSN:

(1) call: 1-800-***-**** or 1-800-***-**** (TTY); or

(2) visit: www.ssa.gov.

RIGHT TO APPEAL

You have the right to ask for a DHS hearing to appeal a decision if you believe it is unfair or incorrect, or if the provider fails to act on your application for benefits. You may file the appeal at:

DHS Office of Hearings and Appeals

PO Box 2675

Harrisburg, PA 17105.

If you appeal, you may also request a conference

before the hearing by contacting the Emergency Rental Assistance Program (ERAP) program manager via

email at: adp6zy@r.postjobfree.com.

At the hearing you may represent yourself, or someone else, such as a lawyer, friend or relative may represent you.

4 PA 600 ERA 2/21

Attestation/Certification

I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is being submitted by someone acting on my behalf. I certify that all information that has been entered is true under penalty of perjury. I understand that the information entered in this application will be kept confidential and used only to administer benefits. I understand that I may be required to work with other agencies as a condition of my approval for assistance. I agree to provide upon request any additional documentation required (i.e. pay stub, lease, recent bills, proof of unemployment etc) to aid in determining eligibility. Signature - Tenant

Name Printed - Tenant

Signature - Landlord (only if form was completed by landlord) Name Printed - Landlord (only if form was completed by landlord) Authorization for Release of Information (Tenant only) I hereby authorize and request the disclosure to the county office any information concerning the age, residence, citizenship, employment, income, and any additional information involving eligibility for the rental and utility assistance programs for myself. It is understood that the information obtained will only be used for determination of rental/utility assistance or other housing assistance programs.

Signature of Tenant Date

Name Printed - Tenant

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