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APPENDIX I - MRAP Applicant EligibilityHouseholds applying for MRAP assistance must meet all four of the following criteria:I.Applicants must be renter households obligated to pay rent on a residential dwelling.II.Household income cannot exceed 80% of the Area Median Income (AMI);III.Since March 13, 2020, at least one member of the household has either:Qualified for unemployment benefitsorExperienced a reduction in household income, incurred significant costs or experienced other financial hardship due directly or indirectly to the Covid-19 outbreak; IV.Since March 13, 2020, at least one member of the household can demonstrate a risk of experiencing homelessness or housing instability.Each eligibility criterion and required submissions are described in more detail below.I.RENTER HOUSEHOLD – An eligible renter household includes households obligated to pay rent on residential dwellings (including, apartments, houses, townhouses, mobile homes, or mobile home lots).Submission Required: For the purposes of this section, “related to” includes any of the following with respect to any member of the application household: the spouse, parent, child, brother, sister, grandparent, grandchild, including steps, and in-laws; and any person cohabitating with any of the people identified above.If a member of the applicant household is not related to the landlord or any employee of the landlord, the applicant must submit: A current written lease signed by the applicant and the landlord that identifies the unit where the applicant resides and establishes a rental payment amount; or One of the following:A Certification of Landlord/Tenant Relationship and verification that the landlord/management agent owns/manages the rental property. See Exhibit A-1 for Certification of Landlord/Tenant Relationship form. Evidence that the household has paid utilities and rent at the residential unit and a Tenant’s Self-Certification of Lease. Evidence may include bank statements, cleared or cancelled checks, or other documentation that reasonably evidence a pattern of paying utilities and rent. See Exhibit A-2 for Tenant’s Self-Certification of Lease.If a member of the applicant household is related to the landlord or any employee of the landlord, the applicant must submit the following:A.A current written lease signed by the applicant and the landlord that identifies the unit where the applicant resides and establishes a rental payment amount; ANDB.Evidence that the tenant’s address is different from the landlord’s address; ANDC. Evidence that the household has paid utilities and rent at the residential unit. Evidence may include bank statements, cleared or cancelled checks, or other documentation that reasonably evidence a pattern of paying rent and utilities. Note: If the Landlord applies on behalf of the tenant, the tenant must also sign the application.II.HOUSEHOLD INCOME CANNOT EXCEED 80 PERCENT OF THE AREA MEDIAN INCOME (AMI). See Exhibit B-1 and B-2 for information on determining household income and AMI limits. Income will be based on one of the following: (A) the household’s total income for the calendar year 2020, or (B) the household’s monthly income at the time of the MRAP application.Submission Required: Must submit the information required by either A or B.An IRS Tax Form 1040 for the year ended 2020 for each member of the household, 18 years or older, that files separately (the 2020 tax return is the preferred method for income but not required)ORFor every member of the household, 18 years or older (see also Note below), provide supporting documentation for the two-month period immediately prior to the application date for all of the following sources of income, as applicable (Also refer to Exhibit B-3 for more detailed descriptions of income included below and a list of exclusions):Wages, salary, tips, bonus, commissions, etc.Severance pay Worker’s Compensation Interest/dividend from assets, including bank accountsNet income from the operation of a business or profession (refer to Exhibit B-3 for additional details), Income from Self-Employment, including direct sales consulting (i.e. Mary Kay, Tupperware), Uber/Lyft services, and online salesUnemployment benefitsSocial Security or Supplemental Security Income (SSI)Annuities, pensions, and retirement funds (i.e. IRA, 401K)Insurance policies, disability, death benefits, or other similar types of periodic receiptsAlimony or child supportRegular contributions or gifts received from organizations or other persons not residing in the dwelling (including online donations such as GoFundMe, or through a local bank)Temporary Assistance for Needy Families (TANF) (if assistance includes an amount specifically designated for shelter and utilities, refer to Exhibit B-3 for additional details)All regular pay, special pay, and allowances of a member of the Armed Forces, except the special pay to a family member serving in the Armed Forces who is exposed to hostile fire (e.g., in the past, special pay included Operation Desert Storm)Note: If the household member is 18 years or older (excluding the head of household and spouse), is a dependent, and is a full-time student, then only the first $480 is included as income.For every member of the household over 18 that cannot provide the documentation required by either A or B above, the application must include one of the following:Self-Certification of No Income (Exhibit C-1). This form should be used only for members 18 years and older living in the household that do not receive any income through any of the above sources.Written Attestation of Income (Exhibit C-2). This form should be used only for members 18 years and older that can’t provide supporting documentation for their income due to extenuating circumstances related to the pandemic, disabilities, lack of technological access or if the income was received in cash. III. SINCE MARCH 13, 2020, AT LEAST ONE MEMBER OF THE HOUSEHOLD HAS EITHER:Qualified for unemployment benefitsorExperienced a reduction in household income, incurred significant costs, or experienced other financial hardship due directly or indirectly to the pandemic.Submission Required - Self-Certification of (i) Unemployment, or (ii) Decreased Income and/or Increased Expenses (Exhibit D).IV.SINCE MARCH 13, 2020, AT LEAST ONE MEMBER OF THE HOUSEHOLD CAN DEMONSTRATE A RISK OF EXPERIENCING HOMELESSNESS OR HOUSING INSTABILITY.Submission Required - Self-Certification of Risk of Homelessness or Housing Instability (Exhibit E).EXHIBIT A-1 – CERTIFICATION OF LANDLORD/TENANT RELATIONSHIP(To be Submitted by Head of Household if no written lease is available) Head of Household’s Name: ______________________________________________________________Head of Household’s Spouse (if applicable): _________________________________________________Other Household Members 18 & Over: _____________________________________________________Landlord’s Name (name where rent is sent): _______________________________________________Landlord’s Address: ____________________________________________________________________Landlord’s Phone Number: _____________Landlord’s Email Address: _______________________Rental Property Address: __________________________________________________ (the “Property”)Term of Lease:__________________________ Expiration of Lease:_________________________Monthly Rent Payment _____________ How long have you rented the Property: ________________Are any utilities included in your rent payment? ? Yes ?No If yes, list which utilities are included: ____________________________________________________________________________.Are you behind in rent: ? Yes ? No If yes, how much rent is past due $_____________?One of the following documents must be attached to this Certification:Evidence that the Landlord owns the property (examples - deed, tax ticket, other proof of ownership); orEvidence the Management Company is authorized to manage the property (example - property management agreement); orEvidence of Rent payments (may include bank statements, cleared or cancelled checks, or other documentation that reasonably evidences a pattern of paying rent) (i) paid by tenant to the Landlord listed in the application; and (ii) for a period of 3 or more months since January 1, 2020.Landlord/Management Company must attach verification that Landlord/Management Company owns/manages the Property. (Attach deed, tax ticket, property management agreement, or other evidence).Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the MRAP Program and other remedies available under applicable law. __________________________________________________________________________Signature of Head of HouseholdPrinted Name of Head of HouseholdDate Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the MRAP Program and other remedies available under applicable law. __________________________________________________________________________Signature of LandlordPrinted Name of LandlordDateEXHIBIT A-2 – TENANT’S SELF-CERTIFICATION OF LEASE(To be Submitted by Head of Household if no written lease is available and Landlord cannot or will not sign Exhibit A-1 Certification of Landlord/Tenant Relationship) Head of Household’s Name: ______________________________________________________________Head of Household’s Spouse (if applicable): _________________________________________________Other Household Members 18 & Over: _____________________________________________________Landlord’s Name (name where rent is sent): _______________________________________________Landlord’s Address: ____________________________________________________________________Landlord’s Phone Number: ____________________________________Landlord’s Email Address: _____________________________________Rental Property Address: __________________________________________________ (the “Property”)How long have you rented the Property? _________________________Term of Lease:__________ Expiration of Lease:__________ Monthly Rent Payment:____________Are any utilities included in your rent payment? ? Yes ?No If yes, list which utilities are included: ____________________________________________________________________________.Are you behind in rent: ? Yes ? No If yes, how much rent is past due $_____________?Applicant must attach the following to this Certification:Evidence of Rent payments (may include bank statements, cleared or cancelled checks, or other documentation that reasonably evidences a pattern of paying rent) (i) paid by tenant to the Landlord listed in the application; and (ii) for a period of 3 or more months since January 1, 2020.And Evidence Utility Payments (may include bank statements, cleared or cancelled checks, or other documentation that reasonably evidences a pattern of paying utilities) (i) paid at the address listed on the application, (ii) for a period of 3 or more months since January 1, 2020; (iii) utility invoice must be dated within thirty days of the application date; and (iv) fully completed Tenant’s Certification of Lease. Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the MRAP Program and other remedies available under applicable law. __________________________________________________________________________Signature of Head of HouseholdPrinted Name of Head of HouseholdDate Exhibit B-3 – Income Inclusions and ExclusionsINCOME INCLUSIONSThe full amount, before any payroll deductions, of wages and salaries, overtime pay, commissions, fees, tips and bonuses, and other compensation for personal services;The net income from operation of a business or profession. Expenditures for business expansion or amortization of capital indebtedness shall not be used as deductions in determining net income. An allowance for depreciation of assets used in a business or profession may be deducted, based on straight line depreciation, as provided in Internal Revenue Service regulations. Any withdrawal of cash or assets from the operation of a business or profession will be included in income, except to the extent the withdrawal is reimbursement of cash or assets invested in the operation by the family;Interest, dividends, and other net income of any kind from real or personal property. Expenditures for amortization of capital indebtedness shall not be used as deductions in determining net income. An allowance for depreciation is permitted only as authorized in paragraph (2) above. Any withdrawal of cash or assets from an investment will be included in income, except to the extent the withdrawal is reimbursement of cash or assets invested by the family. Where the family has net family assets in excess of $5,000, annual income shall include the greater of the actual income derived from all net family assets or a percentage of the value of such assets based on the current passbook savings rate, as determined by HUD;The full amount of periodic amounts received from social security, annuities, insurance policies, retirement funds, pensions, disability or death benefits, and other similar types of periodic receipts, including a lump-sum amount or prospective monthly amounts for the delayed start of a **periodic amount (e.g., Black Lung Sick benefits, Veterans Disability, Dependent Indemnity Compensation, payments to the widow of a serviceman killed in action). See paragraph (13) under Income Exclusions for an exception to this paragraph;**Payments in lieu of earnings, such as unemployment, disability compensation, worker's compensation, and severance pay, except as provided in paragraph (3) under Income Exclusions;Welfare Assistance.Welfare assistance received by the family.If the welfare assistance payment includes an amount specifically designated for shelter and utilities that is subject to adjustment by the welfare assistance agency in accordance with the actual cost of shelter and utilities, the amount of welfare assistance income to be included as Information from HUD Handbook 4350.3 REV-1Exhibit 5-1: Income Inclusions and Exclusions 1Income shall consist of:The amount of the allowance or grant exclusive of the amount specifically designated for shelter or utilities; plusThe maximum amount that the welfare assistance agency could in fact allow the family for shelter and utilities. If the family’s welfare assistance is ratably reduced from the standard of need by applying a percentage, the amount calculated under this paragraph shall be the amount resulting from one application of the percentage.Periodic and determinable allowances, such as alimony and child support payments, and regularr contributions or gifts received from organizations or from persons not residing in the dwelling; andAll regular pay, special pay, and allowances of a member of the Armed Forces, except as provided in paragraph (7) under Income Exclusions.For Section 8 programs only and as provided in 24 CFR 5.612, any financial assistance, in excess of amounts received for tuition, that an individual receives under the Higher Education Act of 1965 (20 U.S.C. 1001 et seq.), from private sources, or from an institution of higher education (as defined under the Higher Education Act of 1965 (20 U.S.C. 1002)), shall be considered income to that individual, except that financial assistance described in this paragraph is not considered annual income for persons over the age of 23 with dependent children. For purposes of this paragraph “financial assistance” does not include loan proceeds for the purpose of determining income.*(Note: This paragraph also does not apply to a student who is living with his/her parents who are applying for or receiving Section 8 assistance.)*INCOME EXLCUSIONS:Income from employment of children (including foster children) under the age of 18 years;Payments received for the care of foster children or foster adults (usually persons with disabilities unrelated to the tenant family, who are unable to live alone);Lump-sum additions to family assets, such as inheritances, insurance payments (including payments under health and accident insurance and worker’s compensation), capital gains, and settlement for personal or property losses, except as provided in paragraph (5) under Income Inclusions;Amounts received by the family that are specifically for, or in reimbursement of, the cost of medical expenses for any family member;Income of a live-in aide, as defined in 24 CFR 5.403;The full amount of student financial assistance paid directly to the student or to the educational institution (see Income Inclusions (9), above, for students receiving Section 8 assistance);The special pay to a family member serving in the Armed Forces who is exposed to hostile fire (e.g., in the past, special pay included Operation Desert Storm);(a)Amounts received under training programs funded by HUD (e.g., training received under Section 3);2Amounts received by a person with a disability that are disregarded for a limited time for purposes of supplemental security income eligibility and benefits because they are set-aside for use under a Plan to Attain Self-Sufficiency (PASS);Amounts received by a participant in other publicly assisted programs that are specifically for or in reimbursement of out-of-pocket expenses incurred (special equipment, clothing, transportation, child care, etc.) and which are made solely to allow participation in a specific program;Amounts received under a resident service stipend. A resident service stipend is a modest amount (not to exceed $200 per month) received by a resident for performing a service for the owner, on a part-time basis, that enhances the quality of life in the project. Such services may include, but are not limited to, fire patrol, hall monitoring, lawn maintenance, and resident- initiative coordination. No resident may receive more than one such stipend during the same period of time; orIncremental earnings and benefits resulting to any family member from participation in qualifying state or local employment training programs (including training programs not affiliated with a local government) and training of a family member as a resident management staff person. Amounts excluded by this provision must be received under employment training programs with clearly defined goals and objectives, and are excluded only for the period during which the family member participates in the employment training program.Temporary, nonrecurring, or sporadic income (including gifts);Reparation payments paid by a foreign government pursuant to claims filed under the laws of that government by persons who were persecuted during the Nazi era. (Examples include payments by the German and Japanese governments for atrocities committed during the Nazi era);Earnings in excess of $480 for each full-time student 18 years or older (excluding the head of household and spouse);Adoption assistance payments in excess of $480 per adopted child;Deferred periodic amounts from supplemental security income and social security benefits that are received in a lump-sum amount or in prospective monthly amounts;Amounts received by the family in the form of refunds or rebates under state or local law for property taxes paid on the dwelling unit;Amounts paid by a state agency to a family with a member who has a developmental disability and is living at home to offset the cost of services and equipment needed to keep the developmentally disabled family member at home; orAmounts specifically excluded by any other federal statute from consideration as income for purposes of determining eligibility or benefits under a category of assistance programs that includes assistance under any program to which the exclusions set forth in 24 CFR 5.609(c) apply. A notice will be published in the Federal Register and distributed to housing owners identifying the benefits that qualify for this exclusion. Updates will be published and distributed when necessary.3The following is a list of income sources that qualify for that exclusion:The value of the allotment provided to an eligible household under the Food Stamp Act of 1977 (7U.S.C. 2017 [b]);Payments to Volunteers under the Domestic Volunteer Services Act of 1973 (42 U.S.C. 5044(g), 5058) (employment through AmeriCorps, Volunteers in Service to America [VISTA], Retired Senior Volunteer Program, Foster Grandparents Program, youthful offender incarceration alternatives, senior companions);Payments received under the Alaska Native Claims Settlement Act (43 U.S.C. 1626[c])Income derived from certain submarginal land of the United States that is held in trust for certain Indian tribes (25 U.S.C. 459e);Payments or allowances made under the Department of Health and Human Services’ Low-Income Home Energy Assistance Program (42 U.S.C. 8624[f]);Payments received under programs funded in whole or in part under the Job Training Partnership Act (29 U.S.C. 1552[b]; (effective July 1, 2000, references to Job Training Partnership Act shall be deemed to refer to the corresponding provision of the Workforce Investment Act of 1998 [29 U.S.C. 2931], e.g., employment and training programs for Native Americans and migrant and seasonal farm workers, Job Corps, veterans employment programs, state job training programs, career intern programs, Americorps);Income derived from the disposition of funds to the Grand River Band of Ottawa Indians (Pub. L- 94-540, 90 Stat. 2503-04);The first $2,000 of per capita shares received from judgment funds awarded by the Indian Claims Commission or the U. S. Claims Court and the interests of individual Indians in trust or restricted lands, including the first $2,000 per year of income received by individual Indians from funds derived from interests held in such trust or restricted lands (25 U.S.C. 1407-1408);Amounts of scholarships funded under title IV of the Higher Education Act of 1965, including awards under federal work-study programs or under the Bureau of Indian Affairs student assistance programs (20 U.S.C. 1087uu);Payments received from programs funded under Title V of the Older Americans Act of 1985 (42U.S.C. 3056[f]), e.g., Green Thumb, Senior Aides, Older American Community Service Employment Program;Payments received on or after January 1, 1989, from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement in In Re Agent-product liability litigation, M.D.L. No. 381 (E.D.N.Y.);Payments received under the Maine Indian Claims Settlement Act of 1980 (25 U.S.C. 1721);The value of any child care provided or arranged (or any amount received as payment for such care or reimbursement for costs incurred for such care) under the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9858q);Earned income tax credit (EITC) refund payments received on or after January 1, 1991, including advanced earned income credit payments (26 U.S.C. 32[j]);Payments by the Indian Claims Commission to the Confederated Tribes and Bands of Yakima Indian Nation or the Apache Tribe of Mescalero Reservation (Pub. L. 95-433);Allowances, earnings, and payments to AmeriCorps participants under the National and Community Service Act of 1990 (42 U.S.C. 12637[d]);4Any allowance paid under the provisions of 38 U.S.C. 1805 to a child suffering from spina bifida who is the child of a Vietnam veteran (38 U.S.C. 1805);Any amount of crime victim compensation (under the Victims of Crime Act) received through crime victim assistance (or payment or reimbursement of the cost of such assistance) as determined under the Victims of Crime Act because of the commission of a crime against the applicant under the Victims of Crime Act (42 U.S.C. 10602); andAllowances, earnings and payments to individuals participating in programs under the Workforce Investment Act of 1998 (29 U.S.C. 2931).5Any allowance paid under the provisions of 38 U.S.C. 1805 to a child suffering from spina bifida who is the child of a Vietnam veteran (38 U.S.C. 1805);Any amount of crime victim compensation (under the Victims of Crime Act) received through crime victim assistance (or payment or reimbursement of the cost of such assistance) as determined under the Victims of Crime Act because of the commission of a crime against the applicant under the Victims of Crime Act (42 U.S.C. 10602); andAllowances, earnings and payments to individuals participating in programs under the Workforce Investment Act of 1998 (29 U.S.C. 2931).55EXHIBIT C-1 – SELF-CERTIFICATION OF NO INCOMEEach household member 18 years or older, who does not receive any income, must complete this formHousehold Member’s Name: _____________________________________________________________Property Address: ______________________________________________________________________Within the last 12 months, did you receive income from any of the following sources?? Yes ?NoWages, salaries, tips, bonus, commissions, etc.? Yes ?NoSeverance pay? Yes ?NoWorker’s compensation? Yes ?NoInterest/dividends from assets, including bank accounts? Yes ?NoNet income from the operation of a business or profession? Yes ?NoIncome from self-employment, including direct sales consulting (i.e. Mary Kay, Tupperware), Uber/Lyft services, and online sales? Yes ?NoUnemployment benefits? Yes ?NoSocial Security or Supplemental Security Income (SSI)? Yes ?NoAnnuities, pensions, and retirement funds (i.e. IRA, 401K)? Yes ?No Insurance policies, disability, death benefits, or similar types of periodic receipts? Yes ?NoAlimony or child support? Yes ?NoRegular contributions or gifts received from organizations or other persons not residing in the dwelling (including online donations such as GoFundMe or through a local bank)? Yes ?NoTemporary Assistance for Needy Families (TANF) ? Yes ?NoAll regular pay, special pay, and allowances of a member of the Armed Forces, except the special pay to a family member serving in the Armed Forces who is exposed to hostile fire (e.g., in the past, special pay included Operation Desert Storm)? Yes ?NoAny other source (if yes, explain) _________________________________________________________________________________________________________________________________.If the answer to any of the above is yes, please return to the income section of your application. Complete the appropriate line item and include the support documentation with your application or complete the self-attestation of income Exhibit C-2 if you do not have supporting documentation of income.Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the MRAP Program and other remedies available under applicable law. I also give the WVHDF and its partners permission to obtain a copy of any tax returns from the Internal Revenue Service and to verify income and other information provided herein from other State agencies.__________________________________________________________________________Signature of Household MemberPrinted Name of Household MemberDateTHIS SECTION TO BE COMPLETED BY THE HEAD OF HOUSEHOLD ONLYDid every household member 18 years and over complete a Self-Certification of No-Income?? Yes ?No If yes, please complete the following:If you declare that no one in your household receives a source of income you must provide a statement of how you meet your MONTHLY living expenses:Monthly ExpenseHow does it get paid?Gift/Loan/OtherWho pays it?Family ClothingRentUtilitiesInternetMedical/Dental CareMedications & PrescriptionsCell Phone/PhoneFoodUnder penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the MRAP Program and other remedies available under applicable law. I also give the WVHDF and its partners permission to obtain a copy of any tax returns from the Internal Revenue Service and to verify income and other information provided herein from other State agencies.__________________________________________________________________________Signature of Applicant/Printed Name of Applicant/Date Head of Household Head of HouseholdEXHIBIT C-2 – WRITTEN ATTESTATION OF INCOME Each household member 18 years or older, who cannot provide supporting documentation for their income due to extenuating circumstances related to the pandemic, disabilities, lack of technological access or if the income was received in cash must complete this form.Household Member’s Name: _____________________________________________________________Property Address: ______________________________________________________________________For each form of income, you must provide pay stubs or proof of income for the past?60 days. If you do not have a proof of income document, you must provide an Employer Attestation using the Attestation Option for your income.Type of IncomeAmount of Household IncomeOver the Last 60 Days1.Wages, salaries, tips, bonus, commissions, etc.2.Severance income from the operation of a business or profession4.Income from self-employment, including direct sales consulting (i.e. Mary Kay, Tupperware), Uber/Lyft services, and online sales5.Worker’s compensation6.Interest/dividends from assets, including bank accounts7.Unemployment benefits8.Social Security or Supplemental Security Income (SSI)9.Annuities, pensions, and retirement funds (i.e. IRA, 401K)10.Insurance policies, disability, death benefits, or similar types of periodic receipts 11.Alimony or child support12.Regular contributions or gifts received from organizations or other persons not residing in the dwelling (including online donations such as GoFundMe or through a local bank)13.Temporary Assistance for Needy Families (TANF)14.All regular pay, special pay, and allowances of a member of the Armed Forces, except the special pay to a family member serving in the Armed Forces who is exposed to hostile fire15.Any other source of incomeIf you listed any income in numbers 1-3 above, please provide:______________________ Name of Employer/Former Employer______________________ Name of Contact Person to Verify Employment______________________ Phone Number of Contact PersonUnder penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge and that I am unable to provide any documentation of the income listed above. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the MRAP Program and other remedies available under applicable law. I also give the WVHDF and its partners permission to obtain a copy of any tax returns from the Internal Revenue Service and to verify income and other information provided herein from other State agencies.__________________________________________________________________________Signature of Household MemberPrinted Name of Household MemberDateEXHIBIT D - SELF-CERTIFICATION OF (I) UNEMPLOYMENT OR (II) DECREASED INCOME AND/OR INCREASED EXPENSES(To be completed by the Head of Household) Complete I or II as applicable:I. ? Since March 13, 2020, a member of my household qualifies for unemployment benefits,______________Date Most Recently Unemployed______________Date Applied for Unemployment______________Date Unemployment Awarded______________Date Re-Employed (if applicable) orII. ? Since March 13, 2020, a member of my household has experienced a reduction in household income, incurred significant costs, or experienced other financial hardship due directly or indirectly to the pandemic. The hardship includes (check all that apply):?Loss of Work/Decrease in Available Hours at Work?Forced Work Closure?Inability to Access or get to Work?Unpaid Wages or other Unpaid Compensation Ordinarily Received ?Increase in Childcare Costs?Forced to Take Off Work due to School Closure or Childcare Change?Self-Quarantined at Home under Government or Medical Recommendation ?Stay at Home or Shelter in Place Order by any level of Government Authority?Forced to Take Off Work to Care for Family Member?Personal or Family Experiencing Illness, Disability, or Mental Health Issues?Lack of Access or Delayed Access to Healthcare?Experience of Food Insecurity, Shortages, or Delayed Benefits?Increase in Family Expenses due to Pandemic or Emergency Preparedness?Unemployment Insurance Unavailable, Insufficient, or Delayed?Emergency Assistance Unavailable, Insufficient, or Delayed?Loss of Social, Financial, or Health Safety Net?Fear and Concern of Future Economic and Health Insecurity and Instability?If I Pay for Rent Now, I Will Not be Able to Meet My or My Family’s Basic NeedsFor applicants certifying to a hardship under section II, please provide additional information explaining your hardship: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the MRAP Program and other remedies available under applicable law. __________________________________________________________________________Signature of Applicant/Printed Name of Applicant/Date Head of Household Head of HouseholdEXHIBIT E - SELF-CERTIFICATION OF RISK OF HOMELESSNESS OR HOUSING INSTABILITYThe MRAP Program requires that since March 13, 2020, at least one member of the household can demonstrate a risk of experiencing homelessness or housing instability.A member of my household has experienced a risk of experiencing homelessness or housing instability. (The hardship does not need to exist as of the date of the application as long as it existed for any period of time since March 13, 2020. For example, if one member of your household faced a risk or eviction or lived in an overcrowded situation between March 13, 2020 and August 1, 2020, your household would be eligible for MRAP assistance under this eligibility criteria.)The hardship includes (check all that apply):?An eviction notice ?A past due utility ?Living in an overcrowded residence (number of household members is greater than the number of total rooms), which can increase the risk of exposure to COVID-19?The household struggles to purchase essential goods or services and pay rent or utilities, such as food, prescription drugs, childcare, transportation, or equipment needed for remote work or school?Monthly rent and utilities are more than the household can afford ?The household is relying on credit cards, payday lenders, or other high-cost debt products, or depleting savings, to pay for rent or utilities, rather than wages or other income?Since March 13, 2020, one or more household members have experienced homelessnessPlease describe your risk of experiencing homeless or housing instability. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the MRAP Program and other remedies available under applicable law. __________________________________________________________________________Signature of Applicant/Printed Name of Applicant/Date Head of Household Head of Household ................
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