cares emergency rental and mortgage assistance customer …€¦ · report all income expected to...
TRANSCRIPT
Revised 08/19/2020
CARES Emergency Rental and Mortgage Assistance Customer Survey
Customer Information. Please fill in the blanks. Name: ________________________________________
Address _______________________________________
Spokane, Washington
Zip Code: _____________
Phone Number: __________________
Demographics. Click on the Option to Select your Answer.
Race / Ethnicity
☐White
☐Hispanic Ethnicity
☐Black/African American
☐Asian
☐American Indian/Alaska Native
☐Native Hawaiian/Other Pacific Islander
☐American Indian/Alaskan Native & White
☐Asian & White
☐Black/African American & White
☐Am. Indian/Alaska Native & Black/African American
☐Other Multi-Racial
COVID-19 Related Community Economic Support Program - CARES Tenant and Homeowner Self-Certification of Annual Income
1
Complete the requested information for all persons in the household.
PART I: ELIGIBILITY CARES funded emergency rental and mortgage assistance is limited to income eligible families whose annual income does not exceed 80% of the Area Median Income (AMI) and who have lost employment or income either permanently or temporarily due to the COVID-19 pandemic.
1 PERSON 2 PERSON 3 PERSON 4 PERSON 5 PERSON 6 PERSON 7 PERSON 8 PERSON $43,350 $49,550 $55,750 $61,900 $66,900 $71,850 $76,800 $81,750
Please check the following box if certifying that this household lost employment or income either permanently or temporarily due to the COVID-19 pandemic.
Experiencing financial hardship
Briefly describe how your household financial situation has changed as a result of the COVID-19 pandemic (e.g., lost employment or reduced income either temporarily or permanently).
PART II: HOUSEHOLD INFORMATION Provide the address where you currently live and your contact information.
Legal Address Street, Apt./Unit #
State, City, Zip Code
Phone Number(s)
Email Address
Enter all household information below and indicate if any member is or will be a part-time/full-time student in the next 12 months. Do not include live-in-aides, children of live-in-aides, foster children, or foster adults.
Household Member #
Name (Last, First, MI)
Relationship to the Head of Household
(co-head, spouse, child, etc.)
Birth Date (mm/dd/
yyyy)
*Student(Part/Full-
time, Neither)
1 Head of Household
COVID-19 Related Community Economic Support Program - CARES Tenant and Homeowner Self-Certification of Annual Income
2
*Note for Applicant: Students do not qualify for HOME assistance unless the individual meets one ofthe exemptions below. Check all that apply:
Over age 24 Veteran of the US Military Married Has dependent child/ren
Member is part of a household that is below 80% AMI Disabled Section 8 Recipient
PART III: ANNUAL INCOME Annual income includes all anticipated recurring income (Section A) and asset income (Section B). Report all income expected to be received in the next 12 months.
Section A – Recurring Income: For each household member (HH Mbr#) below, anticipate annual recurring income for the next 12 months. Include long-term unemployment compensation and all hazard pay. DO NOT INCLUDE: IRS Economic Impact Payments (stimulus checks), Federal Pandemic Unemployment Compensation (the additional $600 per week), income of a live-in-aide, children of live-in-aides, foster children, foster adults, or the income of minors. You may deduct the following amounts from annual income: $480 for reach dependent, $400 if an elderly or disabled family, unreimbursed medical expenses (if exceeding 3% of annual income), and reasonable child care expenses necessary to enable a family member to be employed or further education (per 24 CFR 5.611). Leave blank those that do not apply. Calculate the totals on the last row of this chart.
Income Sources HH Mbr# 1
HH Mbr# 2
HH Mbr# 3
HH Mbr# 4
HH Mbr# 5
HH Mbr# 6
Unemployment Compensation
Wages, salary, overtime, hazard pay, commissions, fees, tips, bonuses (before payroll deductions)
Net income from business and self-employment (include independent contractor/Gig jobs like Etsy, Amazon, eBay, Uber, Lyft, Instacart, Grubhub, etc.)
Interest, dividends, rental, and other net income of any kind from real or personal property
Social Security, including disability/Supplemental
2
3
4
5
6
COVID-19 Related Community Economic Support Program - CARES Tenant and Homeowner Self-Certification of Annual Income
3
Retirement/Pension/Insurance policy/Annuities
Disability or Death Benefits
Worker’s Compensation and Severance pay
Welfare Assistance Payments (TANF)
Regular Pay, special pay, and housing allowance for the Armed Forces (exclude military hazard pay)
Veterans Administration (VA) Benefits (exclude deferred disability benefits)
Adoption Assistance Payments (exclude amount in excess of $480)
Alimony or Child Support
Re-occurring cash gifts from nonprofit, charity, family, or friends who do not reside in the unit
Other (please describe): _______________________________
Total for each HH Member
Section A: Total Income for Household
Section B – Asset Income: For the household, list annual income derived from assets that the household can access. Interest or dividends earned are counted as income even when the earnings are reinvested. Using the categories below, list the type of asset(s), cash value of asset(s), and the annual income derived from the assets. If the asset does not generate income, report zero. If the household member does not have assets, leave blank. Calculate the totals on the last row of this chart.
Household Member #
Assets Categories: Checking, Savings, Mutual funds, Money Market Acct. Equity in Rental Property, Retirement and Pensions, 401(K), Stocks, Bonds, Treasury Bills, Certificate of Deposit, Annuities, Revocable Trust, Mortgages or Deed of Trust, Whole Life Insurance policy, Lump sum- inheritance, Lottery Winnings, Insurance Settlements, Personal property held as an investment (e.g., antiques, gems, etc.)
Cash Value of Asset Interest/Dividends Earned on the Assets
1
2
3
4
5
6
COVID-19 Related Community Economic Support Program - CARES Tenant and Homeowner Self-Certification of Annual Income
4
Household Member #
Disposed Assets: Assets given away for less than the fair market value in the last 24 months with value greater than $1,000, (e.g. sale of a home)
Cash Value of Disposed
Asset
Income from Disposed Asset
Box (B1) Total Value of Assets
Box (B2) Total Income from Assets
***To be completed by Program Administrator***
If Box (B1) Total Value of Assets is greater than $5000, calculate the imputed value of the assets by multiplying
Box (B1) by the Passbook Savings rate of (.06%)
Box (B3) Value of Imputed Asset
$
Section B: Total Income from Assets (greater of box (B2) or (B3)
$
Total Household Annual Income (Add Section A Recurring Income + Section B Asset
Income)
$
PART IV: APPLICANT CERTIFICATION I certify under penalty of perjury that the above information is complete and accurate to the best of my knowledge. I understand that 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. I agree to provide any additional documentation required by the program administer to document my/our household income.
HEAD OF HOUSEHOLD
Signature Printed Name Date
HOME RENTAL And MORTGAGE ASSISTANCE CONTRACT CARES-COVID
LANDLORD or MORTGAGE SERVICER NAME & ADDRESS:
Telephone No. ________________ Email Address: _____________________
DWELLING UNIT ADDRESS & UNIT #: TENANT OR HOMEOWNER NAME:
This CARES-COVID 19 Rental and Mortgage Assistance Contract ("Contract") is entered into between the Spokane Area Workforce Development Council as subrecipient to the City of Spokane Community, Housing, and Human Services Department (herein the “Program Administrator”) and the Landlord/Mortgage Servicer identified above. This Contract applies only to the Tenant or Homeowner and the dwelling unit identified above.
1. TERM OF THE CONTRACT
The term of this Contract shall be in effect until the first occurrence of Tenant or Homeownervacates the unit, Program Administrator fully disburses its share of rent/mortgage payments asdescribed below, or October 31, 2020.
2. SECURITY DEPOSIT
A. The Program Administrator will not pay any security deposit, fine, or fee.
3. RENT/Mortgage AND AMOUNTS PAYABLE BY PROGRAM ADMINISTRATOR
A. Rent or Mortgage. The total monthly rent or mortgage payable to the Landlord/MortgageServicer under the Tenant’s lease or Homeowners Loan Agreement is $______________.
B. Rent Adjustments. Any rent increase requires at least 60 days advance written notice perWashington State law RCW 59.18.140. Also, Governor’s Proclamation 20-19.2 prohibitseviction, notice to vacate, and rent/deposit increase prior to August 1, 2020, a date that may befurther extended by the Governor. Any proposed rent increase may be rejected and not paidby the Program Administrator.
D. Program Administrator Share of the Rent/Mortgage. The Program Administrator shall pay thefull monthly rental amount(s) as full payment of unpaid rent/mortgage for up to four months ofthe contract period below.
Month & Year April 2020 May 2020 June 2020 July 2020 August 2020 September 2020
The Program Administrator does not assume any obligation for the Homeowner’s Mortgage, Tenant's rent, or for payment of any claim by the Owner/Mortgage Servicer against the Tenant/Homeowner. The Program Administrator's obligation is limited to making rent/mortgage payments on behalf of the Tenant or Homeowner in accordance with this Contract.
E. Payment Conditions. The right of the owner to receive payments under this Contract shall besubject to compliance with all of the provisions of the Contract. The Landlord or MortgageServicer agrees that acceptance of Program Administrator’s payment(s) shall be conclusive
October 2020
Total Monthly Rent
evidence that the Landlord/Mortgager Servicer received the full amount due for the month(s), and shall be a certification that:
1. the Contract unit is in decent, safe and sanitary condition, and if rental unit, that theLandlord is providing the services, maintenance and utilities agreed to in the Lease.
2. the Contract unit is leased to and occupied by the Tenant or the Homeowner named abovein this Contract.
3. the Landlord or Mortgage Servicer has not received and will not receive any combination ofrent payments that exceed the monthly rent shown above as rent for the Contract unit.
4. to the best of the Landlord's knowledge, the unit is used solely as the Tenant's principalplace of residence.
F. Overpayments. If the Program Administrator determines that the Landlord or MortgageServicer is not entitled to payments received under this Contract, in addition to other remedies,the Program Administrator may deduct the amount of the overpayment from any amounts duethe Landlord or Mortgage Servicer under this Contract.
4. HOUSING QUALITY STANDARDS AND LANDLORD-PROVIDED SERVICES
A. The Landlord agrees to maintain and operate the Contract unit and related facilities to providedecent, safe and sanitary housing in accordance with 24 CFR Section 882.109 (HousingQuality Standards), including all of the services, maintenance and utilities agreed to in theLease.
B. The Program Administrator shall have the right to inspect the Contract unit and related facilitiesat least annually, and at such other times as may be necessary to assure that the unit is indecent, safe, and sanitary condition, and that required maintenance, services and utilities areprovided.
C. If the Program Administrator determines that the Landlord is not meeting these obligations, theProgram Administrator shall have the right, even if the Tenant continues in occupancy, toterminate payment of the Program Administrator's share of the rent and/or terminate theContract.
5. TERMINATION OF TENANCY
The Landlord may evict the Tenant following applicable state and local laws. The Landlord mustnotify the Program Administrator in writing when eviction proceedings are begun. This may bedone by providing the Program Administrator with a copy of the required notice to the tenant.Program Administrator’s share of the rent shall terminate upon eviction Tenant Family identifiedabove.
6. FAIR HOUSING REQUIREMENTS
A. Nondiscrimination. The Landlord shall not, in the provision of services or in any other manner,discriminate against any person on the grounds of age, race, color, creed, religion, sex,handicap, national origin, or familial status. The obligation of the Landlord to comply with FairHousing Requirements insures to the benefit of the United States of America, the Departmentof Housing and Urban Development, and the Program Administrator, any of which shall beentitled to involve any of the remedies available by law to redress any breach or to compelcompliance by the Landlord.
B. Violence Against Women Act. The Landlord shall comply with the provisions of the ViolenceAgainst Women and Justice Department Reauthorization Act of 2005 (VAWA) further describedin 42 USC 13701 and 14040 and Attachment “A” to this Contract.
7. PROGRAM ADMINISTRATOR TO LANDLORD/MORTGAGE SERVICER RECORDS
A. The Landlord or Mortgage Servicer shall provide any information pertinent to this Contractwhich the Program Administrator.
B. The Landlord or Homeowner/Mortgage Servicer shall permit the Program Administrator or anyof their authorized representatives, to have access to the premises and, for the purposes ofaudit and examination, to have access to any books, documents, papers, and records of theLandlord to the extent necessary to determine compliance with this Contract.
8. RIGHTS OF PROGRAM ADMINISTRATOR IF LANDLORD BREACHES THE CONTRACT
A. Any of the following shall constitute a breach of the Contract:
(1) If the Landlord/Mortgage Servicer has violated any obligation under this Contract; or
(2) If the Landlord/Mortgage Servicer has demonstrated any intention to violate any obligationunder this Contract; or
(3) If the Landlord/Mortgage Servicer has committed any fraud or made any false statement inconnection with the Contract, or has committed fraud or made any false statement inconnection with any Federal housing assistance program.
B. The Program Administrator’s right and remedies under the Contract include recovery ofoverpayments, termination or reduction of payments, and termination of the Contract. If theProgram Administrator determines that a breach has occurred, the Program Administrator mayexercise any of its rights or remedies under the Contract. The Program Administrator shallnotify the Landlord in writing of such determination, including a brief statement of the reasonsfor the determination.
C. The Program Administrator's exercise or non-exercise of any remedy shall not constitute awaiver of the right to exercise that or any other right or remedy at any time.
9. PHA RELATION TO THIRD PARTIES
A. The Program Administrator does not assume any responsibility for, or liability to, any personinjured as a result of the Landlord's action or failure to act in connection with theimplementation of this Contract, or as a result of any other action or failure to act by theLandlord.
B. The Landlord/Mortgage Servicer is not the agent of the Program Administrator and thisContract does not create or affect any relationship between the Program Administrator and anylender to the Landlord, Mortgage Servicer or any suppliers, employees, contractors orsubcontractors used by the Landlord in connection with this Contract.
C. Nothing in this Contract shall be construed as creating any right of the Tenant, Homeowner or athird party (other than HUD) to enforce any provision of this Contract or to asses any claimagainst HUD, the Program Administrator or the Landlord under this Contract.
10. CONFLICT OF INTEREST PROVISIONS
A. No employee of the Program Administrator who formulates policy or influences decisions withrespect to the Rental Assistance Program, and no public official or member of a governing bodyor state of local legislator who exercise his functions or responsibilities with respect to theprogram shall have any direct or indirect interest during this person's tenure, or for one yearthereafter, in this contract or in any proceeds or benefits arising from the Contract or to anybenefits which may arise from it.
11. TRANSFER OF THE CONTRACT
The Landlord shall not transfer in any form this Contract without the prior written consent of the Program Administrator. The Program Administrator shall give its consent to a transfer if the transferee agrees in writing (in a form acceptable to the Program Administrator) to comply with all terms and conditions of this Contract.
12. ENTIRE AGREEMENT: INTERPRETATION
A. This Contract contains the entire agreement between the Landlord or Mortgage Servicer andthe program administrator. No changes in this Contract shall be made except in writing signedby both the Landlord and the Program Administrator.
13. WARRANTY OF LEGAL CAPACITY AND CONDITION OF UNIT
A. The Landlord warrants the unit is in decent, safe, and sanitary condition as defined in 24 CFRSection 982.401 and that the unit is suitable for occupancy by meeting the following conditions:
a. The building is structurally sound, free of rodent infestation, and there is no unresolvedCity of Spokane Code Enforcement notice of violation.
b. The plumbing, electrical, and heating systems are safe, adequate, and in properoperating condition.
c. Locks on all exterior doors work properly. The roof does not leak.d. There is a working smoke detector and carbon monoxide detector.e. If built before 1978, there is no chipped, peeling, and/or chafing painted surface
observed in the rental unit, common area(s), and/or building exterior. Also, Landlordhad provided the EPA notice “Protect Your Family From Lead In Your Home” asrequired by the federal lead-based paint disclosure law 42 U.S.C 4852(d).
B. The Landlord warrants the legal right to lease the dwelling unit covered by this Contract duringthe Term of the Contract.
C. The party, if any, executing this Contract on behalf of the Landlord hereby warrants thatauthorization has been given by the Landlord to execute it on behalf of the Landlord
WARNING: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willingly makes or uses a document or writing containing any false, fictitious, or fraudulent statements or entries, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, or imprisoned for not more than five years, or both.
____________________________________________ Landlord or Mortgage Servicer Name (Print) SIGNATURE(S) OF OWNER/Agent DATE
Attachment “A” VIOLENCE AGAINST WOMEN AND JUSTICE DEPARTMENT REAUTHORIZATIONACT OF 2005 (VAWA)
Purpose of the Addendum
The HOME Rental Assistance Contract for the above referenced unit includes the provisions of the Violence Against Women and Justice Department Reauthorization Act of 2005 (VAWA).
VAWA Protections
1. The Landlord may not consider incidents of domestic violence, datingviolence or stalking as serious or repeated violations of the lease or other“good cause” for termination of assistance, tenancy or occupancy rights ofthe victim of abuse.
2. The Landlord may not consider criminal activity directly relating to abuse,engaged in by a member of a tenant’s household or any guest or otherperson under the tenant’s control, cause for termination of assistance,tenancy, or occupancy rights if the tenant or an immediate member of thetenant’s family is the victim or threatened victim of that abuse.
3. The Landlord may request in writing that the victim, or a family member onthe victim’s behalf, certify that the individual is a victim of abuse and thatthe Certification of Domestic Violence, Dating Violence or Stalking, FormHUD-91066, or other documentation as noted on the certification form, becompleted and submitted within 14 business days, or an agreed uponextension date, to receive protection under the VAWA. Failure to providethe certification or other supporting documentation within the specifiedtimeframe may result in eviction.
HOME RENTAL ASSISTANCE CONTRACT Addendum CARES-COVID
LANDLORD NAME & ADDRESS:
Telephone No. ________________ Email Address: _____________________
DWELLING UNIT ADDRESS & UNIT #: TENANT OR HOMEOWNER NAME:
Please review and certify that you will:
1. Complete the HOME RENTAL and MORTGAGE ASSISTANCE CONTRACT with required residency and location certifications.
2. Not pursue eviction for 6 months after receiving assistance except for specified causes such as
failure to pay rent which becomes due after October 1, 2020.
3. CARES Mortgage or Rental Assistance is available for up to four missed or partial payments
between April 1 – October 1, 2020; payable to the landlord or mortgage servicer in the
amount of 100% of the unpaid amount due.
4. Waive tenant late fees and other penalties.5. Provide tenants with additional time to pay any missed rent payments between April 1, 2020 –
October 1, 2020 not covered by the program at a rate of two months to pay each month of unpaid rent;
6. Release, in writing, any tenant rent obligation for months covered by the program.7. Certify that your participation in the program is voluntary.
____________________________________________ Landlord Name (Print) SIGNATURE(S) OF OWNER/Agent DATE
Revised 08/20/2020
Rental/Lease and Mortgage Confirmation Date:
I, am the: Property Owner/Manager Leasing Agent Mortgage Servicer Other:
Telephone #
Corporation Other
Signature:
Currently, Owns, rents or is listed as a tenant of the residence located at:
Street Address Apt# Spokane, WA
ZIP_______________
Mortgage or Rental Assistance is available for up to four missed or partial payments between April 1 – October 1, 2020; payable to the landlord or mortgage servicer in the amount of 100% of the unpaid amount due. Please complete the following table for the four months that you are requesting rent or mortgage payments assistance.
Month Year
April 2020
May 2020
June 2020
July 2020
August 2020
September 2020
Total Amount Due
Amount Due
The current monthly mortgage or rent payment is: $ . The tenant or homeowner currently owes total past due mortgage or rent (should match Total Amount Due in above Table) in the amount of $________________ .
Please Mail Rent or Mortgage Payable To: Name (Print):
Address:
Address:
City, State ZIP: Account or Loan Number: _______________________________________ W9 must be attached.
In partnership with the Spokane Area Workforce Development Council Spokane Resource Center is an equal opportunity partnership of organizations that provide employment and training services. Auxiliary aids and
services are available upon request to persons with disabilities. Washington Relay Service 711.
October 2020
