HomeMy WebLinkAbout01. Approve COVID-19 Emergency Residential Rental Assistance Program•Lei 0 Lei I Ri 10 VI&I I lot" 4;!&*6j ;9_-Iej
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FROM: OFFICE OF THE EXECUTIVE DIRECTOR
BY: ALDO E. SCHINDLER, DIRECTOR OF COMMUNITY DEVELOPMENT
DATE: JUNE 9, 2020
SUBJECT: COVID-19 EMERGENCY RESIDENTIAL RENTAL ASSISTANCE PROGRAM
Staft recommends that the Downey Community Development Commission of the City of
Downey under its capacity as the Housing Successor Agency, approve an Emergency
Residential Rental Assistance Program for low -to -moderate income Downey residents that ha
experienced COVID-1 9 related economic hardship. I
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Downey residents that have experienced COVI D-1 9 related economic hardship, such as jo�i
loss, furlough, or reduction in hours or pay.
After further review of State of California funding guidelines, it was determined that we could
only use $500,000 of the State's Low -to -Moderate Income Housing Asset Funds. To achieve
City Council's goal of allocating $700,000 for the Program, staff recommends allocating
$200,000 from the City's U.S. Department of Housing and Urban Development, Home
Investment Partnerships ("HOME") funds. Staff will return to the June 23, 2020 City Council
meeting with a recommendation regarding the use of HOME funds for this Program.
As referenced, the first allocation of Program funds will come from the State of California Low -
to -Moderate Income Housing Asset Funds, as administered locally by the Community
Development Commission of the City of Downey Housing Successor Agency (Agency). The
Agency will allocate $500,000 for the Program. The funds will be allocated across two different
fiscal years: $250,000 will be allocated from the current 2019-20 Fiscal Year; and, the
remaining $250,000 will be allocated in the subsequent 2020-21 Fiscal Year.
The Program provides emergency rental assistance grants to income -eligible households.
Income guidelines are based on income requirements established by the State of California,
Housing and Community Development Department, and are listed on page 3 of Attachment
The emergency rental assistance grant is a rental payment made on behalf of an income-
COVID-19 EMERGENCY RESIDENTIAL RENTAL ASSISTANCE PROGRI
JUNE 9, 2020
PAGE 2
eligible household, for a maximum period of one (1) month, to maintain housing and/or to
reduce rental payment delinquency in arrears as a result of the economic downturn during the
COVID-19 pandemic. This rental assistance •ro will be deployed • to provide relief
to botW te-ta-its and landlords.
Eligible households must: reside in the City of Downey; annual household income cannot
exceed the State of California, Housing and Community Development Department established
"Moderate -Income" limits; provide proof of an economic impact during the COVID-19 pandemic
period beginning April 1, 2020 to present; have a current residential lease agreement; have a
current rent balance, amongst other items listed in the Program Application as referenced in
Attachment "A".
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FISCAL IMPACT
There is no fiscal impact to the City's General Fund associated with this program. The
• Development Commission • the City • Downey Housing Successor Agency fund
84 will be used for the Program. The Agency will allocate $500,000 for the Program. The funds
will •' allocated • two different fiscal years: $250,000 will • allocated from the current
2019-20 Fiscal Year; and, the remaining $250,000 will •- allocated in the subsequent 2020-21
Fiscal Year.
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Purpose: The COVID-19 City of Downey Emergency Rental Assistance Program (COVID-19-
DERAP) provides emergency rental assistance grants to income -eligible households
economically impacted during the COVID-1 9 pandemic through job loss, furlough or reduction in
hours or pay, residing in the City of Downey.
Emergency Rental Assistance grants are rental payments made on behalf of an income -eligible
household in an amount determined by the City of Downey, for a maximum period of 1 month to
maintain housing and/or to reduce rental payment delinquency in arrears as a result of the
economic downturn during the COVID-19 pandemic. This rental assistance program will be
deployed immediately to provide relief to both tenants and landlords.
COVID-19-DERAP Eligibility:
Eligible households must meet all of the following criteria:
1. Reside in the City of Downey.
2. Annual household income does not exceed the State of California, Housing and
Community Development Department established " Moderate- Income" limits. Household
income eligibility is based on the following two (2) factors:
a Unit size;
b. The total number of persons residing in the household; and,
c. The total amount of the annual household income.
3. Economically impacted during the COVID-19 pandemic period beginning April 1, 2020-
to present.
4. Current residential lease agreement.
5. Completed W-9 form from bona fide landlord/property management agent or company.
6. Signed Program Participation -Payment Acceptance form from bona fide landlord/property
management agent or company.
7. Confirmed current rental balance.
Attachment "A"
Use of Community Development Commission of the City of Downey Housing Successor
Agency(Agency)Funds:
Agency funds will be used for emergency rental payments on behalf of income -eligible
households with demonstrated economic impact from the COVID-19 pandemic. Monthly rental
assistance is provided for a period of up to 1 month through direct payment to a bona fide
landlord, property management agent or company for current rent and/or to pay down rentals in
arrears occurring on or after April 1, 2020.
Rental Assistance
Rental assistance includes:
a Monthly Rental Payment made on behalf of eligible household to landlord/property
management agent or company in a reasonable amount determined by the agency for
a maximum of 1 month; or
b. Monthly Rental Arrears Payment made on behalf of eligible household to
landlord/property management agent or company in a reasonable amount determined
by the agency for a maximum of 1 month; or
r- Monthly payment combination of items a. and b. made on behalf of eligible household
to landlord/property management agent or company.
Applicant Intake and Assessment Process:
Applications will be accepted on a rolling basis. Grants will be awarded to qualified applicantson
a "first come. first served" basis until funds run out.
Application will be a fillable PDF, made available on the City's website or emailed upon request.
Applicants will attach the completed pdf application, and all supporting documentation requesteal
on the application, to an email sent to rentassistanceftdownevea.org_ln an effort to protect the
environment and prevent the spread of COVID-1 9, paper applications will not be accepted for
this program.
will review application information and provide an eligibility determination in a timely manner. All
applicant household's information and supporting documentation will be recorded accurately in
an applicant file to demonstrate eligibility/ineligibility for this program.
A denied applicant file shall contain all submitted information and documentation, as well as the
reason for denial (ex: over income limits, incomplete information, reside outside service area). A
denial may be appealed by filing a written notice of appeal and any information the applicant
deems relevant to the appeal with the City Manager within 5 days. The City Manager, or his
designee, shall review the information and make a determination within 10 days of receipt of the
notice of appeal and associated documents.
information for all members of an applicant household such as the following:
2
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A kLousehold-is defined as all the persons who occupy a housing unit. The occupants may be
single family, one person living alone, two or more families living together, or any other group
persons who share living arrangements. Therefore, household member information must
include, at a minimum, the following: I
1) Full names and ages of all family members as well as any unrelated persons living
the residence; and i
2) Signature of the primary applicant(s), certifying that the information provided related
to the annual household income and members is correct.
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individuals of the household who have earned or received income during a 12-month period prior
to the April 1, 2020. Additional information on household income is provided in Types on
Household Income section below.
To determine program eligibility, all sources of annual income for each household member over
the age of 18 and the exact amounts earned from each income source must be accurately
documented. The primary applicant(s) are also required to certify by signature that the
information provided regarding household members is correct.
Eligible households must be at or below the "Moderate Income" limits for confirmed household
size. The Emergency Rental Assistance Program Household Income Limits are based on
income requirements established by the State of California, Housing and Community
Development Department, as displayed in this chart:
f,MgRental
Number of Extremely Low- Very Low Income Low-income Moderate -
Persons Income Income
$23,700 $39,450 $63,100 $64,900
2 $27,050
$45,050
$72,100
$74,200
3 $30,450
$50,700
$81,100
$83,500
4 $33,800
$56,300
$90,100
$92,750
:5 $36,550
$60,850
$97,350
$100,150
Is $39,250
$65,350
$104,550
$107,600
-7 $41,950
$69,850
$111,750
$115,000
8 $44,650
$74,350
$118,950
I $122,450
9
12-o-u-M.P.13ting Econg1,11 _j_g_I_M_12g.gt during COVID-19 nandgmir, neriod
Applicant households must submit documentation confirming negative economic impact during
the COVID-19 pandemic period. Acceptable documentation sources include:
• A copy of household member(s) notification of job loss/termination from employer during the
eligible pandemic period (April 1, 2020 to present); or
• A copy of household member(s) notification of furlough from employer during the eligible
pandemic period (April 1, 2020 to present); or
• A copy of household member(s) notification or employer signed form confirming reduction in
hours and/or pay during the eligible pandemic period (April 1, 2020 to present). The
enclosed Form C may be used for this purpose; or
• A copy of household member(s) application during the eligible pandemic period (April 1,
2020 to present) and/or approval for Unemployment Insurance benefits; or
• A notarized affidavit signed that includes the name of the household member who is self-
employed, the name and nature of the business, and narrative confirming economic impact
on self-employment during eligible pandemic period (April 1, 2020 to present).
Emergency rental assistance will be provided for a monthly rent payment and/or a rental
arrearage. Program administrators shall determine the duration and amount of rental assistance
provided to eligible households based on application information, monthly rent due, and amount
in arrears. This duration and assistance amount will be designed to ensure households are
provided with the maximum benefit possible under program limits up to a maximum of 1 month.
Emergency rental assistance will not be paid directly to households. Policies and
procedures must establish how financial assistance is paid to the bona fide landlord/property
management agent or company.
Emergency rental assistance shall be paid by the date specified on the current lease agreement
and program staff will verify proper on -time partial or full rental payment has been made. The
emergency rental assistance program will log all payments made on behalf of eligible households.
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qprifirMina Current LeaAft 6-
greernent
An applicant household must submit a copy of its current residential lease agreement for the
address they reside in as a part of the emergency rental assistance application.
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A completed W-9 form from the bona fide landlord/property management agent or company must
be submitted as a part of the emergency rental assistance application.
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A signed Program Participation -Payment Acceptance form from the bona fide landlord/property
management agent or company must be submitted as a part of an applicant household's
emergency rental assistance application.
Current,,Ep,Ljjgj Ejijjgj]g2
An applicant household must submit a confirmed copy of its current rental balance from the bona
fide land lord/property management agent or company.
A bona fide landlord/property management agent or company is defined as the legal owner and/or
representative of a Single -Family or Multi -Unit residential property leased for the purposes of
permanent housing, entitled to collect rent as prescribed in a valid lease agreement.
In order to process and disburse emergency rental assistance payments to a bona fide
land lord/property management agent or company, signed and completed W-9 and Program
Participation -Payment Acceptance forms are required. The land lord/property management agent
or company will abide by COVID-11 9-DERAP requirements and will be provided with a clear
summary and schedule of payments to be made on behalf of eligible households.
Under no circumstances will the COVID-11 9- DERAP agency or staff be a party to any lease for
which assistance is provided. Program administration contact numbers and information must be
provided in case of questions or concerns.
In addition, the landlord/property management agent or company will be provided with an IRS
1099 form at the end of the calendar year for tax reporting purposes.
Types of Household Income
The following is a list of the types of household income most commonly encountered, as well as
the kinds of documentation required for verification. This is not intended to provide an exhaustive
list of possible income sources, but only those sources most commonly encountered. However,
all applicant income sources must be clearly identified and documented. Applicants must submit
Form A — Household Income Self -Certification and Form B — Individual Income Self -Certification,
to determine annual household income.
A. ag1gry Income: The documentation of salary income must be obtained from at least
one (1) source. The documentation may not be older than six (6) months, except for
Federal and State income tax returns which may not be older than one (1) year. The
0
documentation must be properly labeled and compiled in the applicant's case file in a
readable format. Acceptable sources of income documentation include the following:
Federal or State income tax returns or W2 forms; or
Copies of the applicant's three (3) most recent paycheck stubs, establishing the
applicant's monthly income; or
If above documentation is not available, certification of the applicant's monthly and
annual income from the employer; the enclosed Form C may be used for this purpose,
B. Self -Ern oloymenf- Any income from an adult household member who is self-
employed must be documented and verified from at least one (1) of the following
sources:
• copy of IRS Form 1040/1040A (tax return), if filed with the IRS for the last year; or
• notarized affidavit signed by the applicant that includes the name of the household
member who is self-employed, the name of the business, and the prior year's
estimated annual income.
C. 5ppiall $eir.urjty!,Spp9,jq Mpnt4ry ,rity cqM I Security J2jagWL1tXL
. _$q ppu
Income from Federal or State retirement programs and disability must be verified from
at least one (1) source that may not be older than six (6) months, unless noted below.
Acceptable documentation sources include:
A copy of the applicant's monthly award check; or
A copy of a benefit verification letter (also referred to as an "award letter" or "income
letter' and can be requested from local Social Security office by applicant); or
Copy of a bank statement showing direct deposits of applicant's award check; or
Copy of Social Security Form SSA-2458 which verifies benefits (can be requested
from local Social Security office by applicant); or
Copy of Social Security form SSA-1 099 (tax form mailed each year stating total
amount of benefits received from the previous year.) May not be older than one (1)
year.
Written certification from the awarding agency verifying the applicant's eligibility and
the amount of the monthly benefits; the enclosed Form D may be used for this
purpose.
D. Vaff=LOenergkll
.. , f:. Income from social aid programs [e.g., California Work
Opportunity and Responsibility for Kids (CaIWORKs), Temporary Assistance for
Needy Families (TANF)] must be verified from at least one (1) of the following sources:
Copies of the applicant's most recent bi-monthly award checks.
Copy of most recent Notice of Action or award letter stating the amount of applicant's
benefit; or
Written statement from caseworker stating the applicant's benefit amount; or
n.
Written certification from the awarding agency verifying the applicant's eligibility and
the amount of the monthly benefits; the enclosed Form D may be used for this
salisku
E. Pension Incom%LPension Income must be verified from at least one (1) of the
following sources:
A copy of the pension award letter; or
Copies of the applicant's three (3) most recent payment stubs verifying benefit amount;
or
A copy of the applicant's bank statement demonstrating that the award check was
directly deposited into the applicant's account.
F. ars9npIjn1jqLq§jLPersonal interest from savings accounts or dividends from
financial investments must be identified and documented as earned income. Adequate
verification may include:
Federal income tax return; or
Copies of bank statements; or
All Ljaggg of investment statements indicating the amount of dividends earned.
G. Alimony C received from alimony and/or child support
payments must be documented and verified from at least one (1) of the following
sources:
A copy of applicant's weekly or monthly check; or
A copy of a separation or settlement agreement or a divorce decree from a court
establishing payments; or
A notarized affidavit, signed by the applicant, certifying to the amount of child support
received.
H. In -Home SUoportiye Services: Income earned by a caregiver/caretaker providing in -
home supportive services for a different household must be documented through
copies of the three (3) most recent paycheck stubs, to establish the monthly income.
I. Bpptp! Incorpp: Income received from rental property must be documented as earned
income and must be verified from at least two (2) of the following sources:
A copy of the property rental agreement signed by current tenant stating monthly rent;
A copy of recent rent check; and/or
A copy of the applicant's income tax return declaring earned rental income. May not
be older than one (1) year.
Rent receipt book.
J. N9Jn,;Qm%.,ShouId an adult member of the household (18 years and older) have no
income to report, documentation to be submitted may include:
7
A notarized affidavit signed by the household member declaring he/she does not ea
income that can be contributed to the household; or
Self -certification that the household member does not earn income; the enclosed
Form E may be used for this purpose.
The calculation of annual income §bAD Mqt,j!jql.Vcjp , the following-
L-1
Amounts specifically excluded by any other Federal statue from consideration as
income for purposes of determining eligibility or benefits under a category of
assistance programs that includes assistance under the U.S. Housing Act of 1937.
Amounts paid by a State agency to a family with a member who has developmental
disability and is living at home to offset the cost of services and equipment needed to
keep the developmentally disabled family member living at home.
I. Temnorary Incorra considered temporary, nonrecurring or sporadic in nature
(including gifts).
Irrcor7rra of Full_Tirane Students. earnings in excess of $480 for each full-time student
18 years old or older attending school or vocational training (excluding the head of
household and spouse).
K. ,Ergorly Tax Refunds, including amounts received by the family in the form of
refunds or rebates under State or local law for property taxes paid on the dwelling of
the unit.
The operating agency for the DERAP shall maintain applicant files, landlord/property
management agent or company information, and all program administration (programmatic and
financial) records, written and digital, for no less than a period of 5 years from the end of the
program in accordance with State of California, Housing and Community Development
Department.
The operating agency for the DERAP shall report, approved and assisted households, and their
corresponding assistance information, weekly, or as directed by the funder. The operating
agency for the DERAP shall periodically report to -date households assisted in a numeric and
narrative format as directed by the funder. Financial and programmatic monitoring of the
operating agency will be conducted by Community Development Commission of the City of
Downey Housing Successor Agency staff.
Conflict of Interest
No COVID-19 DERAP funding will be provided to any member of the governing body of the City
of Downey, nor any designee of State of California, Housing and Community Development
Department, or the operating agency who is in a decision making capacity in connection with
the administration of this program; no member of the above organizations shall have any interest,
direct or indirect, in the proceeds from a grant from this program.
9
CHECKLIST
❑ 1. Program Application
❑ 2. Household Income Self -Certification — Form A
❑ 3. Individual Income Self -Certification — Form B (Submit one for each person over 18)
❑ 4. Reduction of Hours/Pay — Form C
❑ 5. Request for Verification of Benefits — Form D*
❑ 6. Zero Income Self -Certification form — Form E*
❑ 7, Lease Agreement
❑8. Program Participation/Payment Acceptance Agreement & Landlord's W-9
*Forms D & E are supplemental forms. Program administration staff may ask for these
forms to complete the eligibility process.
We
0 be
Applicant Tenant:
Tenant Address:
Tenant Phone: | Tenant Email:
MOOthk/R2Dt� | K4Onthk` /DueDate: | KXonth5P@StDue'
' � | '
^ . LANDLORD/LEGAL PROPERTY OWNER MANAGEMENT COMPANY(if applicable) Phone Number
City State Zip
Documenting Economic Impact during COVID-19 Pandemic period of April 1, 2020 to
0 Workplace closure or reduced hours resulting FROM employereconom
impacts of COVID-19: I
Household member(s) notification of job loss/termination from employer
Household member(s) notification of furlough from employer
El Household member(s) notification confirming reduction in hours and/orpay
El Household member(s) application or approval for Unemployment Insurance benefits
El A signed self -certification that includes the name of the household member who is self-
employed, the name and nature of the business, and narrative confirming economic
impact on self-employment during eligible pandernic period
13 Sickness with COVID-19 or caring for a household or family member who is sick
with COVID-19:
11
■ Extraordinary out-of-pocket childcare expenses due to school closures, medic
expenses, or health care expenditures stemming from COVID-19 infection of the
tenant or a member of the tenant's household who is ill with COVID-19: I
Compliance with a recommendation from a •. health authority to stay home,
self -quarantine, or avoid congregating with others during the state of emergency:
F-I Reasonable expenditures stemming from • ordered emergency measures:
ElAny additional factors relevant to the tenant's reduction in income as a result of the
COVID-19 emergency.
IN
INSTRUCTIONS: This is a written statement documenting the Annual Income, the number nfbeneficiary
members in theTamily or household, and relevant characteristics of each member for the purposes of income
determination.
To complete this statement, fill in the blank fields below using information from the attached Individual
Annual Income Self -Certification Form complete and signed by EACH HOUSEHOLD MEMBER AGE 18 OR OLDER
except uIltime students. The applicant Head of Household(s) must then sign this statement to certify that the
information is complete and accurate and that source documentation will be provided upon request.
Applicant:
Address: City Downey
Telephone: | State: CA | Zip Code:
Household Member In me Information
Name: Total Annual Income: HH CH 0HS S2:18 <18 <15 �
> ----
| |
|
/
| | 1 |
MM=Head ofHousehold; CM=Co-Head nfHousehold; DIS=Person with disabilities; S2:1B=Fu||dmestudent age 18or
over; <18 = Child under the age of 18 years; <15 = Minor under the age of 15 years
Annual gross income (total ofall members) =$
I certify that this information is complete and accurate. I agree to provide, upon request,documentation on
all income sources to the City of Downey Emergency Rental Assistance Program Administrator.
Signature
Signature Printed Name Date
vuAnmimG:Theinformation provided onthis form is subject ouverification bvtheCity nfDowney atanytime, and
person isguiltyof a felonyand assistancecan be terminated for knowingly and willingly making a false orfrauclulent
staoementtoadepartmentofthe United States Government.
im
CITY OF DOWNEY — COVID-19 Emergency Rental Assistance Prograrrl
INDIVIDUAL ANNUAL INCOME SELF -CERTIFICATION — Form M
Household Member /PhnLNanne\:
INSTRUCTIONS: To complete this statement, fill in the blank fields below using information from the attached
Individual Annual Income Self -Certification Form complete and signed by EACH HOUSEHOLD MEMBER AGE 18
DROLDER except fuUtimestudents. The Household Member must then sign this statement tocertify that the
information is complete and accurate, and that source documentation will be provided upon request.
Annual Income in Dollars
Self -Employed Profits
Social Security [SS)
Supplemental Security Income (SSI)
Social Security Disability (SSD)
California Work Opportunity and Responsibility for Kids
(Ca|W0RKs)
Temporary Assistance for Needy Families (TANF)
0�=6 A
Unemployment Insurance
Interest from Bank Accounts and Cash Funds
Rental Property Income
Other Income Not Shown Above
| certify that this information is complete and accurate. | agree to provide upon request, documentation
on all income sources to the City of Downey Emergency Rental Assistance Program Administrator.
Signature printed Name Date
WARNING:The information provided on this form is subject to verification bythe City of Downey at anytime,anda
person isguiltyof a felonyand assistancecan be terminated for knowingly and willingly making a false orfraudulent
gatementtoadepartmenunf the United States Government.
W.
To Employer: Date:
Applicant's Address:
I have applied to the City of Downey COVID-19 Emergency Rental Assistance program. I have
pay due to the COVID-19 economic downturn from you. In order for my eligibility to be
determined, the rental assistance program must verify all of my income. The requested
information is for the confidential use of the program and the City of Downey only. Please
furnish the information requested below and return this form, via email to
,rentassistance@ci.downevca.org. If you have any questions about this request, please email the
Program Administrator atr(�,ntassistanco@downevca.org.
(Signature ofApplicant)
7mployee's Name: Position Held:
Dates ofEmployment: From To _
Types of Employment: OPermanent OTemporary OSeasonal Dintermittent
15
(For Income Verification)
RATE OF PAY: (estimated, if not actually paid on hourly, monthly or annual basis):
$_hourly; $ monthly; or $ annually
Additional Compensation: (actual amounts received in past 12 months)
Overtime: $ , Tips $ , Commissions, Bonuses:$
(For Pay and/or Hours Reduction)
RATE OF PAY CHANGE: (estimated, if not actually paid on hourly, monthly or annual basis):
Former Rate of Pay as of LdALmrn V monthly; or $ L_yj: $_hourly; $ annually
New Rate of Pay as of (dd/mm/v)d: $ hourly; $ monthly; or $ annually
REDUCTION OF HOURS WORKED: (estimated if not actual):
Former Regular Hours Worked as of (dd/mm/yy): Hours per _day; _week; or
New Regular Hours Worked as of (ddZmmZyy): Hours per day; week; or_
(Date) (Signature and Title of Employer)
7 =9
M.
To Employer or Local Administrative Office: Date:
From Applicant:
Applicant's Address:
Awarding Agency:
Type of Benefits Awarded: Account Number:
I have applied to the City of Downey COVID-19 Emergency Rental Assistance program. I have
authorized the program to obtain a verification of my income from you. In order for my eligibility
to be determined, the rental assistance program must verify all of my income. The requested
information is for the confidential use of the program and the City of Downey only. Please
furnish the information requested below and return this form, via email to
rentassistance(d�downevca,orq. If you have any questions about this request, please email the
Program Administrator at rentassistancepdowneyca.orq.
Sincerely,
(Signature of Applicant)
.............................................................................................................................
a :
Rame of person on record for whom the benefit is paid:
Account Number: Type of Benefit:
Current Monthly Benefit: Date of original entitlement:
Maximum which could be paid in next 12 months:
Probability of continued entitlement: I
-----
(Date) (Signature and Title of Benefits Person)
17
0 0 N 00 T11=W4=1 __
INSTRUCTIONS: For household members with no income, this certification must be completed
to determine total household income.
THIS ZERO INCOME SELF -CERTIFICATION IS FOR:
Member of Household (Print Name):
COMPLETE THIS FORM IN ITS ENTIRETY
1, (Print Your Full Name) do hereby certify
under penalty of perjury the following: Please check applicable statements.
I hereby certify that I do not individually receive income from any of the following sources:
El a Wages from employment (including commissions, tips, bonuses, fees, etc.);
El b. Income from operation of a business;
El c. Rental income from real or personal property;
0 d. Interest or dividends from assets;
El e. Social Security (SS) / Supplemental Security (SSI) payments, annuities, insurance
policies, retirement funds, pensions, or death benefits to all members;
El f. Unemployment or disability payments;
El g. Public assistance payments (for example, General Relief (GR), TANF, CAPI payments);
0 h. Periodic allowances such as alimonv, child support, familv suggga, or monetary gifts or
otherwise received from persons not living in my household on a regular basis;
El i. Sales from self-employed resources (e.g., Avon, Mary Kay, Shaklee, etc.);
El j. Any other source not named above.
El k. I currently have no income of any kind.
.......... ...... .... __ ...... ......
I understand that false statements or information are punishable under Federal Law. I also
understand that false statements or information are grounds for the denial of my
application for participation in this program. I
Print Name Signature Date
iu.*
Tenant Address:
Management Company (if applicable)
City State
N
E
City of Downey, hereafter referred to as Agency, administers this program and has verified the
lease/rental agreement and other eligibility documentation by the Applicant identified above and
determined that this household is eligible to receive Emergency Rental Assistance. Agency will issue
monthly rental and/or monthly rental arrears payments directly to the land lord/property management
company on behalf of eligible households economically impacted during the COVID-19 pandernic through
job loss, furlough or reduction in hours or pay. This agreement and a completed W-9, Request for
Taxpayer Identification Number and Certification must be completed by the landlord/property
management company and returned to the Agency staff in order to process the payment(s). Payment(s)
will be issued on a monthly basis to the landlord as defined below:
RENTAL ASSISTANCE PROVIDED ANTICIPATED TERMS OF ASSISTANCE
Amount$ For consecutive month beginnin]
AGENCY STAFF NAME (PLEASE AGENCY STAFF DATE TELEPHONE NUMBER
PRINT) SIGNATURE
0
_Sjjp-fro raform
El I do not want to participate in the City of Downey COVID-19 Emergency Rental Assistance
Program; or
1 would like to participate in the City of Downey COVID-19 Emergency Rental Assistance
Program. To receive payment, I will provide this signed agreement a W-9 Request for Taxpayer
Identification Number and Certification.
TENANT'S MONTHLY RENT IS DUE ON THE OF EACH MONTH.
LANDLORD/LEGAL OWNER'S NAME/MGT. COMPANY (PLEASE PRINT)
MAILING ADDRESS CITY STATE ZIP
R, 12 mil I i I ! i A 0 .
PROPERTY ADDRESS CITY STATE ZIP
K11
| UNDERSTAND AND CERTIFY THAT: In no case am | entitled to a payment for a month that the applicant
does not reside at my property. If receive a direct rent payment for a month that the applicant did not
reside at my property, | shall remit toAgency an amount that represents the overpaid rent. To return
such amounts orpayments, | shall call Agency at (562)904-7151 and mail payment to Agency at
11II1 Brookshire Avenue Downey, CA9O241. | must not cash a direct rent payment if the applicant has
moved. | may be prosecuted if commit fraud or knowingly assist an applicant to commit fraud. If am
found guilty ofcommitting fraud, | will no longer be entitled to receive direct rent payments. | may not
acquire rights tosue [Agency] for payment ofrent orfor a breach ofany obligations bythe tenant.
| also understand and certify that | receive no other subsidy and/or assistance from or on behalf ofthis
applicant for full or partial monthly rental payment.
Rental assistance is limited and the duration of assistance as stated in Section I of this agreement. Agency
will make every effort to make rental assistance payments as required by the lease agreement but will
only be responsible for late fees due to administrative errors byAgency staff. | understand that assistance
may be terminated if a participant is determined to be no longer eligible, was never eligible, has not been
fully engaged in the program, and/or has not been fully compliant with program requirements as�
determined by the Agency. Examples non-compliance include failure to return phone calls ore-rnai|s and
failure todisclose all income mrexpenses.
In addition, | understand and agree that during the term of this agreement, | must give Agency a copy of
any notice 1mthe program participant tmvacate the housing unit, or any complaint used under state or
local law tocommence aneviction action against the program participant.
LANDLORD/LEGAL OWNER/MGT. CO. SIGNATURE:
Date'
' TELEPHONE NUMBER:
RE