Employment application
Emergency Rental & Utility Relief ProgramAward ApplicationCT#__________Applicant InformationFull Name of Renter:Date:LastFirstM.I.Address:Street AddressApartment/Unit #CityStateZIP CodePhone:EmailNo. of people in Household:Household Income (all sources required to be reported):Amount Requested:$List all residents in the household:Are you currently receiving unemployment?YES FORMCHECKBOX NO FORMCHECKBOX If yes, how long ________________________Have you experienced hardship due to COVID-19?YES FORMCHECKBOX NO FORMCHECKBOX If yes, explain?Are you homeless or at risk of experiencing homelessness or housing stability?YES FORMCHECKBOX NO FORMCHECKBOX If yes, explain:Landlord InformationFull Name:Rental Amount:Company:Phone:Address:Utility ProviderCompany:Phone:Address:Amount past due:Please refer to attached checklist for required documentation.Please provide a brief description of the events surrounding the need for assistance related to COVID-19.Disclaimer and SignatureI certify that my answers are true and complete to the best of my knowledge. I understand that any misrepresentation, falsification, or omission of any facts called for in this application for rental assistance under the U.S. Department of Treasury’s Emergency Rental Assistance Program may result in non-payment of award.Signature:Date: ................
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