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Declaration of Tenant to Halt Eviction pursuant to 28 U.S.C. §1746

Date

From:

Name:

Address:

City/State/Zip

Phone #

Email Address

Landlord Name:

Name:

Address:

City/State/Zip

Phone #

Email Address

Dear Landlord,

To control the spread of COVID-19, the U.S. Department of Health and Human Services, Centers for Disease Control, has issued an order preventing you from evicting me for nonpayment of rent from the above address until after December 31, 2020. I have requested government rent assistance through Miami Valley Community Action Partnership. Once my application is processed, if you are willing to accept payment, you may receive a check for the past-due and future rent directly from MVCAP. To receive payment, you will need to provide a W-9 and complete MVCAP’s simple landlord statement. I certify under penalty of perjury, pursuant to 28 U.S.C. §1746, that the foregoing information is true and correct:

• I have used best efforts to obtain all available government assistance for rent or housing. I have applied to Miami Valley Community Action Partnership for CARES Act rental assistance provided by Montgomery County or provided through Community Services Block Grant (CSBG) funding for Montgomery, Darke, Preble, or Greene County residents.

• I either expect to earn no more than $99,000 in annual income for Calendar Year 2020 (or no more than $198,000 if filing a joint tax return), was not required to report any income in 2019 to the U.S. Internal Revenue Service, or received an Economic Impact Payment (stimulus check) pursuant to Section 2201 of the CARES Act.

• I am unable to pay my full rent or make a full housing payment due to substantial loss of household income, loss of compensable hours of work or wages, lay-offs, or extraordinary out-of-pocket medical expenses.

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• I am using best efforts to make timely partial payments that are as close to the full payment as circumstances may permit, taking into account my other nondiscretionary expenses.

• If evicted I would likely become homeless and need to move into a homeless shelter or into a new residence shared by other people who live in close quarters because I have no other available housing options.

• I understand that I must still pay rent or make a housing payment, and comply with other obligations that I may have under my tenancy, lease agreement, or similar contract. I further understand that fees, penalties, or interest for not paying rent or making a housing payment on time as required by my tenancy, lease agreement, or similar contract may still be charged and/or collected.

• I further understand that at the end of this temporary halt on evictions on December 31, 2020, my housing provider may require payment in full for all payments not made prior to and during the temporary halt and that failure to pay may make me subject to eviction pursuant to state and local laws. I understand that any false or misleading statements or omissions may result in criminal and civil actions for fines, penalties, damages, or imprisonment. Signature of Declarant Date

*A typed/electronic signature satisfies legal requirements and is permissible pursuant to Ohio Revised Code §1306.06

I gave this declaration to my landlord or their employee on this day of, 2020 by: Handing a copy to my landlord or their employee

Mailing the declaration to my landlord

Emailing a copy of this declaration to my landlord

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