Duplication of Benefits Self-Certification Affidavit

I/, First Name Last Name , affirm that according to law, hereby state under penalty of perjury, the following:
1. I have disclosed all previously received funding through the grants listed below. I also affirm to the fact that I have not received any other type of funding to help assist me with the services I am applying for.
2. I make this affidavit in connection with services that I am applying for through this nonprofit which has been funded by the ESG/CSBG or other Grant.
3.The Recipient has received, or it is reasonably anticipated that the Recipient will receive, the following Federal assistance funding to prevent, prepare for, or respond to the a hardship/homelessness or other crisis (check all that apply AND include amount):

Rental Assistance

Salvation Army Rental Assistance

Mortgage Assistance

City of Garland Rental Assistance

Utility Assistance

Salvation Army Utility Assistance

Emergency Food and Shelter Program (FEMA)

Unemployment (Workforce)

Coronavirus Relief (Fund Treasury)

Economic Impact Payments (Treasury)

SNAP-WIC

Summer Food Program Assistance (USDA)

Emergency Food Assistance (USDA)

Pandemic EBT (USDA)

Snap Emergency Allotment (USDA)

4. The Recipient understands that, should the US Department of Housing and Urban Development (HUD) determine that the Recipient has received a duplication of benefits, the Recipient may be required to repay a portion or all of the assistance provided by HUD.

Signature: Signature*
Client Name:First Name* Last Name*
Today's Date:Date*