City of Fort Wayne Emergency Rental Assistance Program ...

Return application to Brightpoint Email: gethelp@ Fax: 260-420-8067 Phone: 1-800-589-3506 and follow the prompts for Emergency Rental Assistance

City of Fort Wayne Emergency Rental Assistance Program Application

Please complete this application in its entirety and have all required documentation prior to submittal. The last page of this application contains a checklist of required documentation. For questions or support, please reach out to the community partner you received this application from or contact:

PHONE: 317-552-1463 E-mail: rent@

Paper applications should be returned to the community partner that you received the application from or rent@.

Applicant Contact Information: Applicant Name:_________________________________________________ Applicant Mailing Address: _________________________________________ City:__________________ State:_________ Zip Code:___________________ Phone number (required):________________ E-mail Address:___________________________

Required documentation: You must submit one of the following types of documentation:

Driver's license or other state-issued ID U.S. or foreign passport

Legal permanent resident card (Green card) Current foreign government issued ID

U.S. visa

Office of Refugee Resettlement ID

Work permit Matr?cula consular

Military ID Social security card

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Applicant Eligibility Questions: 1. Do you meet all of the eligibility criteria listed below: ________Yes ________No a. I am a resident of the City of Fort Wayne, IN b. I am at risk of homelessness or experiencing housing instability c. I, or a member of my household, have qualified for unemployment or have experienced a reduction in household income, incurred significant costs, or experienced a financial hardship due to COVID-19

2. Enter the complete address for the residence for which you are applying for rent and/or utility assistance. To be eligible for assistance you must be currently occupying the rental unit.

Rental Unit Address: _____________________________________________

City:__________________ State:_________ Zip Code:___________________

Required documentation: Attach a copy of an executed lease agreement in the applicant's name, valid during the timeframe for which you are applying for assistance. If you do not have a lease agreement in the applicant's name, you must submit one of the following documents in addition to the Landlord Attestation Form.

? Photo id with address of rental unit ? Current (within 60 days) utility bill listing name of applicant and address of rental

unit ? Mail from a government office, financial institution or utility provider listing

name of applicant and address of rental unit

3. Did you have past due rent payments prior to March 13th, 2020? This will not disqualify you from receiving assistance as part of this program.

________Yes ________No

4. Did you have past due utility payments prior to March 13th, 2020? Note: this will not disqualify you from being eligible for this program.

________Yes ________No

5. What is the gross household monthly or annual income? This must include income for all adult household members.

$________________Gross household annual income OR

$________________Gross monthly household income

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Required documentation:

You do not need to submit ALL of the documents listed below. You should submit any documents that are issued to you and/or members of your household which document your household income.

Proof of Annual Income ? 2020 tax return listing all adult household members ? 2020 W-2(s) for every job held by each adult household member ? 2020 1099(s) for every job held by each adult household member ? 2020 1099G unemployment compensation statement

Proof of Monthly Income ? Monthly unemployment compensation statement for the two months prior to application ? Pay stubs for the two months prior to application ? Most recent stipend(s), alimony, child support, pension/retirement/annuity monthly award letter(s) ? Letter from employer verifying salary/wages for the two months prior to application ? Most recent SSI or SSDI statement of benefits

6. Have you or someone within the household been unemployed for at least 90 days prior to the date of application submittal?

________Yes ________No

7. I, or a member of my household, have qualified for unemployment or have experienced a reduction in household income, incurred significant costs, or experienced a financial hardship due to COVID-19.

________Yes ________No

Required documentation: One of the following documents must be included as part of

your application. You may have already included one of these documents in response to

another question, in which case, you do not need to submit an additional document from

this list.

? Most recent unemployment statement

? Notice of business closure (letter from

? Discharge, layoff, or furlough letter ? Pay stubs showing reduction in work

hours ? Pay stubs showing reduction in

income

employer of closure, closure announcement in newspaper, etc.) ? Documentation of significant costs incurred, such as child or dependent care or medical expenses

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8. What is the total number of adults (18 years or older) living in the household?: __________

9. What is the total number of minors (younger than 18 years) living in the household?: ______

10. Enter the total monthly rent payment you are responsible for making to your landlord. DO NOT include any rental assistance you receive from federal, state or local assistance programs that reduces the amount of rent you are responsible for.

Monthly Rent Payment: $_____________

11. Do you certify that the total monthly rent amount entered above is the tenant-owed (the amount you pay) portion of your rent and does not include any federal, state or local rental assistance?

________Yes ________No

12. Are you applying for assistance with past due rent payments? ________Yes ________No

Required documentation: Copy of rent statement showing past due amount and monthly rental amount. Should be on letterhead of landlord/property manager. If a rent statement is not available, the Landlord Attestation Form must be completed by the landlord and include the past due rent amount.

13. Are you applying for assistance with future rent payments? ________Yes ________No

Required documentation: Landlord Attestation Form signed by the landlord and showing future rent amounts OR executed lease agreement showing agreed upon rent amount for the current lease.

14. Complete the table below for all utilities for which you are seeking assistance. Note, you must attach past due utility bills showing amounts due after March 13th, 2020:

Utility

Electric Gas Water

Sewer/wastewater

Trash/refuse

Utility Provider (i.e. AEP, NIPSCO, City of Fort Wayne

Utilities)

Is this payment included in the rent you pay to your landlord (Yes/No)?

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Required documentation: Statement of past due payments from the utility company, listed by month. If possible, obtain a statement from your utility provider that shows monthly and total past due amounts owed after March 13th, 2020.

15. Are you on a payment plan with the City of Fort Wayne Utilities? Note this does not make you ineligible for assistance.

________Yes ________No Applicant Demographic Questions: Note the following questions are required for collection per the U.S. Department of Treasury but have no impact on the applicant's eligibility for assistance.

16. Select one of the following for applicant's gender: Male

Female

17. Select one of the following for applicant's race:

White Black/ African American Asian American Indian / Alaskan Native Native Hawaiian / Other Pacific Islander American Indian / Alaska Native & White Asian & White Black / African American & White American Indian / Alaskan Native and Black / African American Other Multi-Racial

18. Are you of Hispanic, Latino or Spanish origin?: ________Yes ________No

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