Re-Certification of Eligibility for Ongoing ERUC Assistance

Instructions

This data is collected for purposes of a 3 month re-certification of eligibility for the Your Way Home Emergency Rent and Utility Coalition’s program in response to COVID‐19 (ERUC-CV). This is a verbal statement from the beneficiary documenting current monthly Gross Income, the number of beneficiary members in the family or household, and the relevant characteristics of each member for the purposes of income determination. For the purposes of this regulation, income will be defined according to the Code of Federal Regulations at 24 CFR, Part 5. The information provided on this form is subject to verification at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government. All adult beneficiary members must then sign this statement to certify that the information is complete and accurate, and that source documentation will be provided upon request.

I/we have read and understand

Personal Information

First Name *

Last Name *

Date of Birth *

xx/xx/xxxx

Email *

Phone *

Address *

Address

City

State/Province

Zip/Postal

Other Household Members

Are there any other persons in the household? *

Yes

If so, how many?

Other Persons in Household

First Name *

Last Name *

Relationship to Primary Applicant *

Date of Birth *

xx/xx/xxxx

Social Security Number

xxx-xx-xxxx

Sex/Gender

Race

Ethnicity

Add Remove

Household Income – Head of Household and Other Adults in the Household

Only report on regular, recurrent income sources that are current as of today (i.e. not terminated). Include any income received to your household that a minor receives (e.g. SSI), however income from employment of a minor can be excluded.

Do you or any other Adult Household Member have any current income from any source? *

Monthly Earned Income (i.e., Employment Income)

Monthly Unemployment Insurance

Monthly Supplemental Security Income (SSI)

Monthly Social Security Disability Income

Monthly VA Service-Connected Disability Compensation

Monthly VA Non-Service-Connected Disability Pension

Monthly Private Disability Insurance

Monthly Worker’s Compensation

Monthly Temporary Assistance for Needy Families (TANF)

Monthly General Assistance (GA)

Monthly Retirement Income from Social Security

Monthly Pension or Retirement Income from a Former Job

Monthly Child support

Monthly Alimony or Other Spousal Support

Other

Please specify source

Certification

Each person signing below certifies to the following: To the best of my knowledge, the ERUC participants named above meet all requirements to receive ongoing assistance under the Your Way Home ERUC program. To the best of my knowledge and ability all of the information used in making this eligibility determination is true and complete. *

I/we have read and understand

Date *

xx/xx/xxxx

Signature *