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Rental Assistance Application
Rental Assistance Application
2020-05-03T16:28:03-07:00
Solicitud en español
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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:
*
Job loss, furlough or layoff
Reduction in hours of work or pay
Store, restaurant or office closure
The need to miss work to care for a home-bound, school age child or elderly person
Illness
Other
Other, please explain:
Last Date of Employment or Date of Reduction in Pay
*
MM slash DD slash YYYY
Your Rental & More
Your Local Address
*
Street Address
Mailing Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is this your only and primary residence?
*
Yes
No
Monthly Rent Amount:
*
For which month are you requesting assistance?
*
January
February
March
April
May
June
July
August
September
October
November
December
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
*
Max. file size: 50 MB.
Upload l ast pay stub or statement from employer describing employment and the fact that the applicant was impacted from COVID-19.
*
Max. file size: 50 MB.
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!
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