(If you are unable to pay rent due to loss of income related to COVID-19 and you feel that you qualify please complete this application)

(TO BE COMPLETED BY APPLICANT) (Head of Household):

For the purposes of this application - "Hispanic or Latino" - is a person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture/origin, regardless of race.  The term, "Spanish origin", can also be used.

*This information is being collected to ensure compliance with demographic reporting requirements.

If you checked any of the above: Have you contacted your Housing Authority to readjust your rent amount?

If you do not have a voucher CONTINUE.

Housing Type for Primary Residential unit:

     Rental Home

Adult Household Member(s) (HHM) 18 and older

Adult Household Member 1 (HHM1)

Adult Household Member 2 (HHM2)

For the purposes of this application - "Hispanic or Latino" - is a person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture/origin, regardless of race.  The term, "Spanish origin", can also be used.

*This information is being collected to ensure compliance with demographic reporting requirements.

CHILD HOUSEHOLD MEMBERS (HHM) UNDER the age of 17

If there are no household members age 17 and younger, please click the Next button to continue.

For the purposes of this application - "Hispanic or Latino" - is a person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture/origin, regardless of race.  The term, "Spanish origin", can also be used.

*This information is being collected to ensure compliance with demographic reporting requirements.

INCOME INFORMATION (PRE-COVID-19):  Income includes: Wages, salaries and tips, alimony, child support, military income, part-time income, temporary income, TANF, Social Security, other benefits, other income for all household members over the age of 18.  List ALL household members and their incomes.  Attach a separate sheet if you need more space, or  the “Income Source” table provided and their incomes.  Attach a separate sheet if you need more space or use the “income Source” table provided immediately below.
FOOD STAMPS ARE NOT CONSIDERED INCOME – do not list food stamps.
STIMULOUS CHECK – is not considered income

OTHER ASSISTANCE RECEIVED:

Applicant Certification - Certify that all information in the application is true, to the best of your knowledge.  By signing this application, the applicant authorizes the City of Aurora or any of its duly authorized representatives to verify the information contained herein.

I/We understand the information provided above is collected to determine if I/We are eligible to receive assistance under the City of Aurora Emergency Housing Assistance Program for households economically impacted by COVID-19.
I/We hereby certify that providing false statements or information is grounds for termination of housing assistance and is punishable under federal law.
I/We authorize the City of Aurora Emergency Housing Assistance Program and any of its authorized representatives to verify all information provided in this application.
I/We understand that additional information will likely be required to move forward with this program.
I/We understand that I/We may be responsible to repay/return any duplicated benefits received in concert with this program or any of the other assistance received hereafter.
Please sign this application below certifying that you understand and agree that you may be responsible for repaying any other benefits that are determined to be duplicated of the assistance received from this program.

Notice: Due to the nature of this program, and to avoid additional unnecessary contact, a typed name on this form will constitute the legal equivalent of your signature for the purposes of this application.  

Warning:

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.

ELIGIBILITY RELEASE: It is required that you sign this form, which allows the City of Aurora to request information from Third Parties concerning your eligibility and participation in this program.

Information Covered: Inquiries may be made about items including:
Income (all sources including dependent income), Assets (all sources), Child Support, Rental Amount.

Instructions to Applicant: Your signature on this Eligibility Release, and the signatures of each member of your household who is 18 years of age or older, authorizes the city of Aurora or any of its duly authorized representatives to obtain information from a third party regarding your eligibility and continued participation in the Emergency Housing Assistance Program (COVID-19).  

Privacy Act Notice Statement:  The City of Aurora requires the collection of the information listed in this form to determine an applicant’s eligibility for the Program.  This information will be used to establish the level of benefits for which the applicant is eligible and to verify the accuracy of the information furnished.  information received from an applicant or as a result of verifying the applicant’s eligibility may be released to appropriate Federal, State, and Local government and local agencies, or when relevant, to civil, criminal, or regulatory investigators, and to prosecutors, Failure to provide any information may result in delay or rejection of your eligibility approval.  Subrecipient is authorized to ask for this information under the National Affordable Housing Act of 1990.

NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN.

Applicant’s Authorization:

I authorize the above-named Nonprofit, State or Local Government or Vendor to obtain information about me and my household that is pertinent to determining my eligibility for participation in the Program, I acknowledge that: 
(1) A photocopy of this form is valid as the original; AND
(2) My printed name will act in lieu of a written signature for the purposes of this form: AND
(3) I have the right to review information received using this form; AND
(4) I have the right to a copy of information provided to the Subrecipient and to request correction of any information I believe to be inaccurate; AND
(5) All adult household members will sign this form and cooperate with the subrecipient in the eligibility verification process.

WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.

If an agency did not prepare the application, please click the submit button.