Tenant Forms

Complete, Sign and Submit Tenant Certification, COVID 19 Impact Statement, HMIS Release of Information and Intake Form
(All must be submitted)

Are you behind on your rent and need assistance?

Name(Required)

County(Required)

Phone(Required)

Landlord Name(Required)

Landlord Phone(Required)

Please attach your most recent utility statement(s) for which you would like assistance

Max. file size: 50 MB.

Tenant Certification

"*" indicates required fields

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Required checkbox

1. I have occupied the unit for which I am seeking assistance as my principal residence during the time for which the rental or utility arrears assistance is requested and will occupy the unit as my principal residence throughout the remaining months for which the assistance is provided.

Required checkbox

2. I have disclosed all Housing Choice Voucher or Project-Based, or Public Housing Rental Assistance, and I am not receiving any other form of government or charitable assistance for the tenant portion for the months of rent for which this assistance is requested, such as tenant-based voucher assistance (such as Section 8), or project-based assistance.

Required checkbox*

3. I will not seek to obtain rental or utility assistance in the future for the same months of rental arrears, rent, utility arrears, or utilities covered by this assistance. If I do receive such duplicative assistance I will report it to Landlord and/or Utility Provider using the contact information in my lease or utility bill statement, and to the Emergency Rental Assistance Alabama Program.

Required checkbox*

4. I have provided a current written lease as part of the application, or if I have not provided a current written lease, I have provided documentation of residence which may include evidence of paying utilities for the residential unit, an attestation by a landlord who can be identified as the verified owner or management agent of the unit, or other reasonable documentation as determined by the program.

Required checkbox*

5. I understand that if determined to be ineligible, I can appeal the decision byfollowing the appeal instructions at www.https://eraalabama.com/

Required checkbox*

6. I acknowledge that all information collected, assembled, or maintained by the Emergency Rental Assistance Alabama Program pertaining to their application, except records made confidential by law or court order, are subject to the Alabama Open Records Act. Under the Act Emergency Rental Assistance Alabama Program must provide any interested person with reasonable access to all records pertaining to this application and other than personally identifiable information protected by law.

Required checkbox*

7. I shall provide the U.S. Department of the Treasury, the U.S. Inspector General, the U.S. General Accounting Office, the Alabama Comptroller, the Alabama State Auditor’s Office, the Office of Court Administration and the Alabama Housing Finance Authority (AHFA), or any of their duly authorized representatives, access to and the right time, I agree to keep records of my payment to the Landlord for the later of five years, or Such records will be kept for the longer of five years after notice of a monitoring, audit, or litigation has been provided, and the matter has had a final disposition.

Required checkbox*

8. I have been provided a copy of this certification.

Required checkbox*

9. I may remain responsible for charges presented with my utility bill, such asdistrict assessments or cooperative fees, that are presented separately from the charges for utility service.

Required checkbox*

10. I may remain responsible for charges authorized under the lease other than rent going forward, including but not limited to pet rent or trash pickup fees.

Required checkbox*

The information I have provided is true, accurate, and complete, and if requested, I am able to provide documentation to prove my household’s loss of income or additional expenses. I understand that providing false, incomplete, or inaccurate information on application forms or seeking assistance for months in which assistance has been or will be provided, may result in termination of participation in the Program and possible criminal liability.

Required checkbox*

I authorize my landlord to submit my information to ERA Alabama on my behalf. Furthermore, I authorize ERA Alabama’s Customer Service Representatives to complete my application based on the information above and information provided by my landlord.

Signature*

Date*

Comments

This field is for validation purposes and should be left unchanged.

Tenant Forms

Are you behind on your rent and need assistance?

Tenant Certification

Tenant Certification

Partners

Newsletter Subscription

Address

P.O. Box 113
Troy, AL 36081-0113

Contact Us

Tel: 334-273-0668

Email: info@archconnection.org

Fax: 334-273-0669

Contact Us

Fill in the form below and we'll get in touch

Tenant Forms

Are you behind on your rent and need assistance?

Tenant Certification

Tenant Certification

Partners

Newsletter Subscription

Address

P.O. Box 113Troy, AL 36081-0113

Contact Us

Tel: 334-273-0668

Email: info@archconnection.org

Fax: 334-273-0669

Contact Us

Fill in the form below and we'll get in touch

P.O. Box 113
Troy, AL 36081-0113