RENTAL ASSISTANCE APPLICATION

ELIGIBILITY FOR RENTAL ASSISTANCE (One-time Payment of Up to $1,000 Paid Directly to Landlord/Property Manager)

To be eligible for the Rental Assistance Program, you must live in Washington County, your household income must be at or below 125% of the federal poverty guidelines, and you must have an Eviction notice, late rent notice, or letter from landlord/property manager confirming amount of past due rent. You also must provide proof of income for all household members 18 and older. Applications cannot be processed without complete information and supporting documentation.

SUPPORTING DOCUMENTATION NEEDED TO APPLY

Driver's License or Photo ID
Proof of Income for Previous Month for all Household Members (Including Pay Stubs; Self-Employment Income; Social Security Income (SSA); Supplemental Security Income (SSI); Supplemental Security Disability Income (SSDI); Child Support; TEA; Alimony; Unemployment benefits; Worker's Compensation; Veterans Benefits; Retirement Benefits, etc.)
Eviction notice, late notice, or letter from landlord confirming amount of past due rent
Social Security Number

COMPLETING THIS APPLCIATION

APPLICANT: All Sections of this form must be completed in order to determine your eligibility. Failure to complete this application and provide required documentation WILL delay the processing of your application. To qualify for the program, applicants must meet State eligibility requirements.

APPLICANT INFORMATION

HOUSEHOLD INFORMATION

Race:I =American Indian/Alaskan Native, A =Asian, B =Black or African American, P =Native Hawaiian or other Pacific Islander, W =White, MR =Multi-Race, O =Other, NR =Choose not to respond

Gender:M =Male, F =Female, NR =Choose not to respond

Education:8=0-8thGrade, NG=9-12 Non-Graduate, HSG=High School Graduate, GED=GED, SC=Some College or Post-Secondary CD =2 or 4 year College Degree, GD =Graduate Degree or above

Name(s) of Household Members	Relationship to Applicant	Date of Birth MM/DD/YYYY	Veteran Yes or No	Active Military Yes or No	Disability Yes or No	Hispanic = Yes Not Hispanic = Yes	See the Codes Above
Name(s) of Household Members	Relationship to Applicant	Date of Birth MM/DD/YYYY	Veteran Yes or No	Active Military Yes or No	Disability Yes or No	Hispanic = Yes Not Hispanic = Yes	Race	Gender	Education	Health Insurance Yes or No

HOUSEHOLD NON-CASH BENEFITS

Check any benefit that you or your household currently receive:

HOUSEHOLD INCOME

List the monthly amount of any income that you or your household currently receives. Please use gross income. Gross income is what you earn before taxes and deductions.

Source of Income	Applicant	Additional Household Member	Additional Household Member	Additional Household Member
Employment (Adults Only)	$	$	$	$
Self-Employment (Adults Only)	$	$	$	$
TANF	$	$	$	$
Child Support/ Alimony	$	$	$	$
Supplemental Security Income (SSI)	$	$	$	$
Social Security Disability (SSDI)	$	$	$	$
Social Security Retirement	$	$	$	$
VA Disability Compensation	$	$	$	$
VA Disability Pension	$	$	$	$
Retirement/Pension	$	$	$	$
Unemployment Insurance	$	$	$	$
Worker’s Compensation	$	$	$	$
Private Disability Insurance	$	$	$	$
Other:	$	$	$	$

YesNo

My household has received NO income for the previous month.

If you claim No Income, you will need two statements verifying you have zero income and documenting how you have paid living expenses.

REASON FOR NEED OF RENTAL ASSISTANCE

List the monthly amount of any income that you or your household currently receives. Please use gross income. Gross income is what you earn before taxes and deductions.

Job Loss or Layoff

YesNo

Reason related to COVID-19 Pandemic

YesNo

Other:

YesNo

The information I have provided is true and correct. I will provide documentation to verify my residency, the size of my household and income. I understand completion of this application does not guarantee that I will be eligible to receive rental assistance from CEO.

I am providing my signature electronically by typing my first and last name below.

Applicant Signature:

Date:

STAFF ONLY DATE RECEIVED: FORM VERSION: 06.2020:

Approved:

Denied:

Over-Income:

APPLICANTS RIGHTS AND RESPONSIBILITIES

I understand that I have the right to appeal any decision regarding this application which I consider improper, and also any delay in decision or delivery of services.

I understand that I must help establish my eligibility by providing as much information as I can about my circumstances.

I authorize the contracted agency to release information relating to my application for Rental Assistance to my landlord/property manager to determine eligibility.

I give permission to the Arkansas Department of Human Services to use information provided on this form for purposes of research, evaluation and analysis of the program.

I understand tbat my landlord/property manager will have no control over the data disclosed pursuant to this consent, and will not be responsible for monitoring or taking any steps to ensure that the CSBG office maintains the confidentiality of the data or uses the data as authorized by you.

I understand that no person may be denied assistance -on the basis of race, color, sex, age, handicap, religion, national origin, or political belief.

I understand that my signature on this application authorizes the agency to make any investigation concerning me or any household member and/or use a copy as a release of information for securing information needed to determine my eligibility for services.

I understand that if I receive assistance to which I am not entitled as a result of withholding information or knowingly providing false or fraudulent information regarding my circumstances, I must repay the cost of any assistance and may face penalty of criminal prosecution.

The information given on this application is true to the best of my knowledge and belief. I understand that this form is signed subject to penalties for perjury.

If your application is complete, please click the submit button below. You will be contacted to schedule a phone interview. Please gather the documents below, prior to your interview:

Driver's License or Photo ID
Water Bill or Disconnect Notice
Social Security Number
Proof of Income for Previous Month for Household Members 18 and older (Including Pay Stubs; Self-Employment Income; Social Security Income (SSA); Supplemental Security Income (SSI); Supplemental Security Disability Income (SSDI); Child Support; TEA; Alimony; Unemployment benefits; Worker's
Compensation; Veterans Benefits; Retirement Benefits, etc.)