Rental Assistance Application

Your Contact Information

Applicant Name*

First Last

Applicant Phone*

Applicant Email*

More than one Applicant?

Yes
No

Name of Tenant(s) on lease (if different than application)

Phone Number

Email

Your Landlord's Information

Name of Landlord*

First Last

Landlord Mailing Address*

Street Address Address Line 2 City State ZIP Code

Landlord Phone Number*

Your Covid-19 Situation

Please explain your financial hardship as the result of COVID-19. Examples of impact by COVID-19 include but are not limited to:*

Other, please explain:

Last Date of Employment or Date of Reduction in Pay*

Your Rental & More

Your Local Address*

Street Address Mailing Address City State ZIP Code

Is this your only and primary residence?*

Yes
No

Monthly Rent Amount:*

For which month are you requesting assistance?*

select ONE month per application

Other bills or payments (and dates) for which you are past due:

Are you receiving unemployment payments*

Yes
No

Amount of rent Applicant can pay:

List Household Members and their ages:

Provide written statement on need for rental assistance:

I Will Provide BOTH:*

Copy of the lease agreement
Last pay stub or statement from employer describing employment and the fact that the applicant was impacted from COVID-19.

Upload Copy of Lease Agreement*

Upload l ast pay stub or statement from employer describing employment and the fact that the applicant was impacted from COVID-19.*

Consent*

By clicking the checkbox here, the applicant attests that all information provided is true and correct.

Self Declaration of COVID-19 Economic Impact*

I hereby declare under penalty of perjury that my income has been negatively impacted by COVID-19 and the public health emergency. I declare that the information stated above and in my application for rental assistance is true to the best of my knowledge and I understand that any misrepresentation may be grounds for termination of my or family/household’s rent payment assistance. If it is determined that you have applied for rental assistance fraudulently, you may be required to return any assistance provided under false pretense that was provided under this program. I agree that if my income status changes in any way, I will notify Mammoth Lakes Housing in subsequent applications for rent payment assistance and provide evidence of my household income.

Signature

Payment will be made directly to the landlord within 20 days of approval, provided that the landlord gives the Town a receipt for the payment, indicating the property address and the name of the tenant(s). Notice of payment will be provided to the landlord and applicant within 5 days of approval. The Town’s or its designee’s decision on any application shall be final, and the terms of this program may be amended, or the program itself eliminated, at any time without notice. Mammoth Lakes Housing is an equal opportunity provider of services and programs and will not discriminate against any applicant on the basis of race, color, national origin, religion, sex, gender identity, pregnancy, disability, age, medical condition, ancestry, marital status, citizenship, sexual orientation, or status as a Vietnam-era veteran or special disabled veteran.

Once you click SUBMIT, your will receive a copy of this form via email. Stay Healthy!