• Image field 123

  • Rental Assistance Program Application

  • STAFF ONLY

  • REF# * RECEIVED BY * DATE
    Ā Ā Ā Ā Ā Ā Pick a Date*Ā Ā Ā Ā Ā Ā 

  • Applicant

  • Head of Household?
  • Currently receiving Housing assistance?*
  • If YES, please indicate which type of housing assistance: you receive:*

  • Co-Applicant

  • Head of Household?*
  • Currently receiving Housing assistance?*
  • If YES, please indicate which type of housing assistance: you receive:*

  • FAMILY MEMBER INFORMATION

  • (Applicant & Co-Applicant will be required to provide 3 months of bank statements)

  • Rows

  • AMI 0ā€30% >30ā€50% >50ā€80% Over 80%

  • HOUSING & EMPLOYMENT INFORMATION

  • Please be note that we will contact your Property Manager and Employer for additional information and documentation.

  • By checking one of the statements belowā€”You may be required to provide proof to document the statement.

  • CHECK ALL THAT APPLY

  • FINANCIAL HARDSHIP QUESTIONNAIRE/SCREENING QUESTIONS

  • Please complete the requested information and place a check mark next to the statement that
    most closely reflects your current situation since the COVIDā€19 Disaster Declaration

  • A. EMPLOYMENT

    COMPLETE REQUESTED INFORMATION AND CHECK ALL THAT APPLY
    A determination of financial hardship due to lost employment or income either permanently or temporarily due to the eļ¬€ects of the COVIDā€19 pandemic.

  • I was employed in a position working*
  • Since the Shelterā€inā€Place order was instituted, I have been:*
  • EMPLOYMENT*
  • and has guaranteed return to myprevious position and scheduled hours.
    Ā -Ā -
    2 digit month, 2 digit day, 4 digit year
  • I am currently receiving unemployment compensation

  • B. HOUSINGĀ (Rental Assistance)

    COMPLETE REQUESTED INFORMATION AND CHECK ALL THAT APPLY
    A determination of housing crisis due to lost employment or income either permanently or temporarily due to the eļ¬€ects of the COVIDā€19 pandemic.

  • I am experiencing a housing crisis and facing potential homelessness due to loss of income when COVIDā€19 Shelterā€inā€Place was institutā€
    ed. My monthly rent payment is $ and is due on (day and month)

  • B. HOUSING

  • 1. I owe back rent for a total of months, and the total amount of $ for rent past due PRIOR to the COVIDā€19 Shelterā€inā€Place being instituted.

  • 2. I owe back rent for a total of months, and the total amount of $ for rent past due AFTER the COVIDā€19 Shelterā€inā€Place was instituted.

  • 3. owed in the amount of $ PRIOR to March 16, 2020 and $ AFTER March 16,2020 .

  • 4. (fill in details on table below).
    Rows

  • **QUESTIONS ā€œCā€ THROUGH ā€œGā€ ARE OPTIONAL (for informational purposes only)**

  • C. UTILITIES
    A determination of hardship and inability to pay for basic utilities due to lost employment or income either permanently or temporarily due to the eļ¬€ects of the COVIDā€19
    pandemic. Basic Utilities include: Water, Electric, Gas

    CHECK ALL THAT APPLY

  • C. UTILITIES*

  • D. CHILDCARE
    A determination of hardship and inability to pay for proper child care due to lost employment or income either permanently or temporarily or day care is closed due to
    the eļ¬€ects of the COVIDā€19 pandemic. Childcare is for a child/children age 0ā€12 years of age.

    COMPLETE REQUESTED INFORMATION AND CHECK ALL THAT APPLY

  • Prior to the restrictions associated with the COVIDā€19 pandemic I had proper childcare for my child/children:*
  • If I were to return to work when the COVIDā€19 restrictions are lifted:*

  • E. FOOD
    A determination of financial hardship and inability to pay for an adequate amount food due to lost employment or income
    either permanently or temporarily due to the eļ¬€ects of the COVIDā€19 pandemic.

    Ā 

  • CHECK ALL THAT APPLY*

  • F. TRANSPORTATION
    A determination of hardship and inability to pay for transportation to access certain necessary services due to lost employā€
    ment or income either permanently or temporarily due to the eļ¬€ects of the COVIDā€19 pandemic. Necessary services inā€
    clude: grocery stores, pharmacies, child care, employment.

    Ā 

  • CHECK ALL THAT APPLY*
  • 1
  • 2

  • G. HEALTH/MEDICAL/PRESCRIPTIONS
    A determination of hardship and inability to pay for medical/prescriptions due to lost employment or income either permaā€
    nently or temporarily due to the eļ¬€ects of the COVIDā€19 pandemic. . Childcare is for a child/children age 0ā€12 years of age.

  • CHECK ALL THAT APPLY*
  • Prescription Insurance:

  • AUTHORIZATION FOR RELEASE OF INFORMATIONSELF CERTIFICATION STATEMENT OF ANNUAL INCOME BY BENEFICIARY

  • I declare under penalty of perjury that the information provided in this application is true and accurate to the best of myknowledge. I understand that willfully and knowingly making a false or fraudulent statement on this application is a felony thatmay be punishable by jail time and/or a fine. I also understand that the information provided on this form is subject to verifica-tion by the City of Vista and the United Stated Department of Housing and Urban Development at any time.All household members age 18 years and over

  • 1. Date*
    Ā -Ā -
    2 digit month, 2 digit day, 4 digit year
  • Clear
  • 2. Date
    Ā -Ā -
    2 digit month, 2 digit day, 4 digit year
  • Clear
  • 3. Date
    Ā -Ā -
    2 digit month, 2 digit day, 4 digit year
  • Clear
  • Should be Empty: