Application for Emergency Rental Assistance

Application for Emergency Rental Assistance

*Please note- All documents must be uploaded on this form-Please allow one to two week for application review-Upon approval please allow 7-14 business days for payments to be processed*
Who's applying?
How did you hear about this program?
Tenant Name

First NameLast Name
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Number of Adults in Household
Number of Children under 18 in Household
Has anyone in your household experienced financial hardship which may include, but not be limited to, a period of unemployment, a decrease in household income, or had increased household costs?
If yes, Please provide us a short detailed explanation.
If Yes, was this financial hardship due, directly or indirectly, to COVID-19?
Is anyone in your household at risk of homelessness or housing instability?
Has anyone in the household received federally-funded rental assistance in the past 12 months?
Are you a veteran?
Has anyone been a victim of domestic violence?
Citizenship:

Other
Race (check all that apply):

Other
Ethnicity:
Gender:

Other
Landlord or Property Manger Information
Property Management Company (if applicable)
Name

First NameLast Name
Tax ID Number or Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Tenant Utility Information

Rows	Company Name	Address (Street, City, Zip)	Phone	Account Number
1
2
3
4
5

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?
If yes, check all that apply, and list the income you have already received

Other

Income

Rows	Name of Person with Income	Type/Source of Income/Name of Employer	Income/Pay: How Much?	How Often Paid	Date of Most Recent Payment
1
2
3
4
5

Tenant Household Expenses

Rows	Monthly $	Arrears $
Rent
Electric
Gas
Oil
Propane
Coal/Wood/Other
Trash
Water/Sewer
Internet

Notes
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) 619-0403 (voice) or (800) 537-7697 (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: 1-800-772-1213 or 1-800-325-0778 (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: RA-PWERAPOIM@pa.gov.

At the hearing, you may represent yourself, or someone else, such as a lawyer, friend or relative may represent you.
Document Upload
Government-issued or other personal ID for at least one household member on the lease

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Copy of rent or lease agreement (or rent receipt)

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Evidence of unemployment benefits, if applicable

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Notices of late rent payment or notice to evict, if applicable

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Copies of past due utility bills if utility assistance is being requested

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Income Documentation
If you have completed your household's federal income taxes for 2020, you will need to provide one of the following:
- Filed 2020 IRS Form 1040
- Filed 2020 IRS Form 1040-A
- Filed 2020 IRS Form 1040-EZ
If you have not yet completed your federal income taxes for 2020 OR you are not required to filed a federal income tax return for 2020, you will need to provide all of the applicable income documentation under one of these two categories:

Acceptable annual income documentation
- 2020 IRS Form W-2
- Current Social Security benefits letter or 2020 FOrm 1099-SA (including benefits paid to minors)
- 2020 Form 1099-R
- 2020 IRS Form 1099-MISC for contractor income
Other acceptable income documentation:
- Check stubs from your employer for the previous 90 days
- Current unemployment benefits letter including gross benefit amount
- Current letter from your employer verifying gross wages (pay rate, hours/week, pay date)
- Current pension/retirement benefit letter (if applicable)
- Current annuity payment letter
- Current interest statement 1099-INT
- Current dividend statement 1099-DIV
- Certification of income form (for self-employed or cash income)
- Zero income form
Income documentation for all household members

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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

First NameLast Name
Signature - Landlord (only if form was completed by landlord)
Name Printed - Tenant

First NameLast Name
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 - Tenant
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name Printed - Tenant

First NameLast Name
Should be Empty:

Application for Emergency Rental Assistance

Landlord or Property Manger Information

Rights and Responsibilities

Document Upload

Income Documentation

Attestation/Certification

Authorization for Release of Information (tenant only)