YUMA COUNTY ERAP FORM IN ENGLISH Step 1 of 9 11% ApplicantFull Name* First Last Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address - (if different than home address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you rent your residence?*YesNoDo you live on tribal land?*YesNoPhone*Alternate PhoneEmail* Contact Preference* Phone Email Mail Text List All Members of Household, Including ApplicantFull Name* First Last Relationship*Date of Birth* Date Format: MM slash DD slash YYYY Age*Please enter a number from 0 to 200.Sex*Currently Receiving Income?*YesNoHave you been unemployed more than 90 days?*YesNo Full Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY AgePlease enter a number from 0 to 200.SexCurrently Receiving Income?YesNoHave you been unemployed more than 90 days?YesNo Full Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY AgePlease enter a number from 0 to 200.SexCurrently Receiving Income?YesNoHave you been unemployed more than 90 days?YesNo Full Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY AgePlease enter a number from 0 to 200.SexCurrently Receiving Income?YesNoHave you been unemployed more than 90 days?YesNo Full Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY AgePlease enter a number from 0 to 200.SexCurrently Receiving Income?YesNoHave you been unemployed more than 90 days?YesNo Full Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY AgePlease enter a number from 0 to 200.SexCurrently Receiving Income?YesNoHave you been unemployed more than 90 days?YesNo Full Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY AgePlease enter a number from 0 to 200.SexCurrently Receiving Income?YesNoHave you been unemployed more than 90 days?YesNo Income Information: PROVIDE INCOME INFORMATION FOR ALL MEMBERS CURRENLTY RECEIVING INCOME: Full Name*Type of Income?*Frequency:*$*Full NameType of Income?Frequency:$Full NameType of Income?Frequency:$Full NameType of Income?Frequency:$ SELF-ATTESTATION OF ZERO INCOME: I, the APPLICANT, do hereby certify that the following adult household member(s) do NOT receive income from any source. I understand sources of income include, but are not limited to the following: Wages, salaries, and tips, Social Security benefits, Unemployment compensation, Self-employment or business income, Child Support, Alimony, Retirement and pension income, Investment and rental income, or any other source of income not named here. I ATTEST on behalf of the household that the ADULT member(s) below do NOT receive income from any source: Full Name:Age:Please enter a number from 0 to 200. Full Name:Age:Please enter a number from 0 to 200. Full Name:Age:Please enter a number from 0 to 200. Full Name:Age:Please enter a number from 0 to 200. Financial Hardship due to COVID-19 Pandemic declared on 03-13-2020: Financial Hardship Attestation: Had anyone in your household qualified for any kind of unemployment insurance benefits, including PUA, PEUC, Extended benefits?*(PUA-Pandemic Unemployment Assistance) (PEUC) Pandemic Emergency Unemployment Compensation) YesNoIf yes, briefly explain:*When did this happen?* Date Format: MM slash DD slash YYYY Has anyone in your household had a significant increase in expenses (costs) due to COVID-19?*YesNoIf yes, briefly explain:*When did this happen?* Date Format: MM slash DD slash YYYY Had anyone in your household had a financial hardship directly or indirectly related to the COVID-19 public health crisis?*YesNoIf yes, briefly explain:*When did this happen?* Date Format: MM slash DD slash YYYY Is anyone in your household at risk of being homeless or having unstable housing?*YesNoIf yes, briefly explain:*When did this happen?* Date Format: MM slash DD slash YYYY Do you live in unsafe or unhealthy conditions?*YesNoIf yes, briefly explain:*When did this happen?* Date Format: MM slash DD slash YYYY Rental and Utility Information: Has anyone in your household received any rental or utility assistance since March 13, 2020?*YesNoIf yes, who provided the assistance that was received?*When?* Date Format: MM slash DD slash YYYY For which months did you receive assistance?*Was the assistance for:*RentUtilitiesBothDo you owe back utilities for any months?*(Electric/Gas/Water/Sewer/Trash Disposal fee)YesNoProvide information if you are applying for utilities assistance:UTILITY PROVIDER NAMEACCOUNT NUMBERMONTHS PAST DUETOTAL PAST DUE AMOUNTUTILITY PROVIDER NAMEACCOUNT NUMBERMONTHS PAST DUETOTAL PAST DUE AMOUNTUTILITY PROVIDER NAMEACCOUNT NUMBERMONTHS PAST DUETOTAL PAST DUE AMOUNTUTILITY PROVIDER NAMEACCOUNT NUMBERMONTHS PAST DUETOTAL PAST DUE AMOUNT DOCUMENTS TO INCLUDE to this Pre-Qualification packet:Landlord Verification Form - Landlord Must Fill Out* Drop files here or Proof of Covid-19 related financial hardship*(You must provide at least ONE of the following: termination letter from your former employer, paystubs from enough pay cycles to substantiate a reduction in income proof of unemployment insurance or PUA application or weekly claim submittal, Employer letter stating change in hours, wage reduction or notice of furlough, receipts to prove increased expenses or proof of other financial hardship directly or indirectly due to covid-19) Drop files here or Applicant’s Photo ID only* Drop files here or Copy of your current lease or rental agreement*Applicant must be listed on or have signed the lease agreement Drop files here or 5-day notice/Eviction notice (if applicable) Drop files here or Due Utility Bills(if applying for utilities)(Electric/Gas/Water/Sewer/Trash Disposal fee) Drop files here or Proof of Income:*Income Documents for ALL household members Submit: complete 2020-1040 Tax Return OR Income from the last 2 months (I.e., paystubs, unemployment benefits, social security benefits, pension, etc.) Drop files here or AFFIRMATION: I affirm I have not received assistance or a commitment for rental/utility assistance from any other source for the same time period and type of assistance. If I am approved for this program and I end up receiving rent assistance from another source, I will inform WACOG. RELEASE OF INFORMATION: By signing below, I hereby consent to and authorize WACOG and/or delegate agency to contact me or any other source necessary to establish the accuracy of the information given by me. Furthermore, I authorize any landlord, utility company to which payment on my behalf may be made, to release information regarding my current account including, but not limited to, billing information to Yuma County ERA Program or its contract designee. I understand that WACOG and Yuma County ERA Program may use information provided on this form for purposes of research, evaluation, and analysis. If eligible, I give my permission to WACOG to forward the completed application to Yuma County ERA Program to be processed for payment to the Landlord or Utility Vendor, by the Emergency Rental Assistance Program. I hereby state under the penalties provided by law that the statement/s above and the household information on this pre-qualification packet is true, correct and complete to the best of my knowledge. I Understand that WACOG and Yuma County reserves the right to deny a household who provides false information for the current program. Applicant's Signature:* First Last Date:* Date Format: MM slash DD slash YYYY Below is a summary of your application. Please review to make sure all information is accurate. If you need to make any corrections please select Previous. Should all information is correct please confirm your submital at the bottom. {all_fields}NameThis field is for validation purposes and should be left unchanged.
