EMERGENCY RENT ASSISTANCE

EMERGENCY RENT ASSISTANCE

COVER PAGE TENANT NAME(S) & PHONE NUMBER:

PROPERTY ADDRESS:

OWNER/MANAGER NAME & PHONE NUMBER

Applications may be turned in by owner/manager or tenant

ALL PAGES & DOCUMENTATION MUST BE TURNED IN AT THE SAME TIME!Owner/Manager Forms (ID required w/ W-9 for Individuals/Sole Proprietor of Property)

Tenant FormsIncome for all persons 18 or Older Identification for ALL Household Members Lease & *12-Month Rent Payment History *If Tenant residency is less than 12-Months, provide history from move-in date

Ledger MUST show Credits/ Payments and Total Due

PARTIAL or INCOMPLETE APPLICATIONS WILLBE RETURNED TO THE APPLICANT

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INSTRUCTIONS FOR SUBMITTING

EMERGENCY RENT ASSISTANCE APPLICATIONS

EFFECTIVE DATE: JANUARY 1, 2021

THE CITY OF LUBBOCK COMMUNITY DEVELOPMENTDEPARTMENT WILL ACCEPT COMPLETE APPLICATIONS

BY ONE OF THE FOLLOWING METHODS: • THROUGH THE COMMUNITY DEVELOPMENT DROP-BOX

1708 CRICKETS AVE.Inside Lubbock Housing Authority

o APPLICATIONS MUST BE IN A SEALED ENVELOPE WITH NAME AND ADDRESS VISIBLE

o HOURS MONDAY - FRIDAY, 8:00AM – 5:00 PM

• MAILED VIA U.S. MAIL TO: COMMUNITY DEVELOPMENTPO BOX 2000

LUBBOCK, TX 79457

INCOMPLETE APPLICATIONS WILL BE RETURNED TO APPLICANT

The City follows all Fair Housing laws and will not discriminate against any person on the basis of race, color, religion, national origin, age, sex, familial status or

disability. Special accommodations will be made as requested, including in-person assistance with completing applications.

CONTACT 775-2296 FOR MORE INFORMATION

Applications must contain Original Signatures from Owner/Property Manager and Tenant/ Applicant.

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COMMUNITY DEVELOPMENTEMERGENCY RENTAL ASSISTANCE PROGRAM

PROGRAM OVERVIEW AND REQUIRED DOCUMENTATIONThe Emergency Rental Assistance Program helps eligible tenants economically impacted by the COVID-19 pandemic stay in their homes, by providing rental assistance. Assistance is available for both tenants who have been sued for eviction or tenants struggling to pay their rent.

Assistance can be used to pay the full contracted rent within the limits noted below and within the written guidelines of the Administrator, for at least one month of rental payments going forward and up to five months of arrears, for up to a total of six months. Any rental payments going forward must be for consecutive months.

LANDLORD, OWNER &/OR PROPERTY MGR TENANT / HOUSEHOLD

Minimum Eligibility Requirements:

Assistance for rent not older than 11 months from current month

Must have a bank account & accept payments via check or Direct Deposit

Units that are already receiving project-based rental assistance , are public housing units, or are owned by a unit of government may be ineligible.

REQUIRED Documents :

Completed IRS *W-9 form SIGNED BY PROPERTY OWNER or Authorized Representative. ID required for sole-proprietor/ individual. (If you have previously submitted, do not resubmit.)

Copy of the executed lease with the tenant which includes all months for rent being requested. Must provide old lease if necessary.

12-MONTH RENT PAYMENT HISTORY/ LEDGERREQUIRED (Or from Move-In date if less than 12-monts),which shows any payment or partial payments made, and totaldue.

Leasing Agreement Required between Owner and Landlord/ Agent

Landlord forms completed and signed, including HQS forms for property inspection.

You Must Certify:

PROOF OF TENANCY: Written Lease must include all months for which rent is requested. If renewal, must provide expired lease if months requested are covered.

NO DUPLICATION OF BENEFITS: You have not received or applied for assistance from another program for the same months of rent for this client and will not apply in the future. You will reimburse the City of Lubbock within 10 business days if you receive rent for the same time period.

NON-EVICTION: You will release the tenant from payment liability for this time period, waive all claims raised if there is currently an eviction case, and not evict the tenant for the period covered by the program.

HOUSING QUALITY STANDARDS: You must agree to an HQS inspection and Lead-Based Paint requirements. Inspections are performed based on property age, type, history, etc.

Minimum Eligibility Requirements:

Household income below 80% of Area Median Income (AMI) limit *See next page*

Household has been financially affected by COVID-19 Pandemic & in financial recovery from loss of income

Tenant may be Ineligible if they receive a tenant-based voucher assistance, are in a unit receiving project-based assistance, or are in public housing. You MUST PROVIDE evidence of recertification.

REQUIRED Documents: IDENTIFICATION for every household member ELIGIBLE ID'S: Adults- State-issued ID or Passport; Minors- Photo ID, Birth Certificate, Social Security Card, School Registration, Passport, etc. (ID cannot be expired & must present ID with current address)

INCOME for every household member, INCLUDING 60-days Pay Stubs, Cash Payments, 12-months Child Support, SNAP/TANF, Social Security, Unemployment, Retirement, etc. (see page 5) >Unemployment Notices and Payment History>Pending Award Letters for SNAP, Social Security, etc.>Pay Stubs Prior to & After hours reducedComplete Application and Certification includingdemographics for ALL household members, signature anddates.

You MUST Provide and Certify:

PROOF OF TENANCY: Provide Copy of Lease- must be signed by both the property manager/ owner and the tenant. It must include the months for which rent is being requested.

NO DUPLICATION OF BENEFITS: You must disclose previous rental assistance. This information is verified with the State and Federal Governing Agencies.

SEE NOTICE BELOW

COVID-19 IMPACT: Explain how your household IS RECOVERING FROM the financial impacts of COVID-19 pandemic. You must provide a description of how you are trying to recover financially including job prospects if you are unemployed or pending application for disability caused from contracting COVID.

NOTICE TO LANDLORD/OWNER & TENANT: It is a criminal offense to accept funds or apply for assistance for ANY PERIOD of time in which a tenant is not residing in property or vacates prior to end of Lease. Any funds received after a tenant vacates property must be returned IN FULL. Under Title 18, Section 1001 of the United States Code, failure to comply may leave you subject to fines, imprisonment or both. Such offenses will be reported to USDT and to TDHCA.

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COMMUNITY DEVELOPMENT EMERGENCY RENTAL ASSISTANCE PROGRAM

Income Eligibility

Program is available to persons living within the City limits of Lubbock and who are experiencing financial hardship due to the COVID-19 pandemic. To qualify, households must meet the following criteria:

• Income Eligibility:o Loss of Income Must Be Directly Due to COVIDo Income Verification must be submitted, and may include the following:

Pay-stubs showing before and after hours cut Notice of termination due to COVID or Notice of Furlough Unemployment for last 12-Months (or from date of loss of income Child Support for last 12-Months SNAP, LIHEAP or SSI Award Letter Detailed statement when and why loss of income occurred

o Household May Be Automatically Considered Income-Eligible if: Household has 6 or less members and are receiving SNAP,

LIHEAP or SSI (for the head-of-household or co-head-of-household) benefits LIHEAP Medicaid

Living in Rent-Restricted property, has evidence of income certification on or after April 1, 2020, or within one (1) year of the household assistance application, and self-certify that income does not exceed 80% of the Median Income for family size.

Financial Impact Statement: You must provide an explanation of how you have been and/or continue to be financially impacted by Coronavirus. This may include loss of job due to cut-backs or illness due to contracting COVID. Additional situations may include caring for a family member, increased household expenses to help prevent spread of the virus, recovering savings that you expended when original income loss occurred, etc. Provide dates of loss, specific circumstances and explain how your household is attempting to recover financially (i.e. new job, decrease living expenses, etc.).

EMERGENCY RENTAL ASSISTANCE PROGRAM

LANDLORD/ Property Owner FORM AND CERTIFICATION

Page 1 of 3

A. Administrator: CITY OF LUBBOCK COMMUNITY DEVELOPMENTB. Tenant Information1. Name(s) on Lease or Proof of Tenancy documentation:2. Contact information for Tenant (Phone and/or email):

C. Unit Information1. Unit Address:2. Number of Bedrooms:

3. Year of Construction*:* Note that if the unit was constructed after 1978, the unit may be subject to HQS inspection requirements.

4. Unit Monthly Contract Rent: $5. Period of Lease: to

6. Is the unit’s rent income restricted by HUD, USDA or TDHCA?: Yes No

7. *List Months Past Due, including Current Month:

8. New Move-In Application Fee and/or Deposit, if applicable:

9. Total Amount of Rental Assistance Requested:

D. Owner/ Landlord Information

1. Owner Name: Owner Mailing Address:

2. Landlord/ Agent Name (if applicable):

Landlord Phone: Owner/Landlord/Agent email:Landlord/Agent Address:

Owner Phone:

E. Applicable to Eviction Diversion cases ONLY:Court Case # (Docket #): Justice of the Peace (J.P.) Precinct # in Lubbock County

LANDLORD/ PROPERTY OWNER PLEASE READ EACH ITEM CAREFULLY & INITIAL BY EACH ITEMBy signing below, Landlord certifies:

1. The Tenant(s) named above currently occupies the Unit identified above and for which assistance is being requestedand that this application is submitted during tenants occupancy.

2. Property Owner/ Landlord understands that this program requires participation from both the Property Owner/Landlord and a Tenant and if none of the Tenants of the Unit elect to do so, no assistance will be provided.

3. Property Owner/ Landlord is not requesting assistance for any month of assistance prior to April 2020.

4. Landlord must accept payment from Administrator by check payable to Property Owner or authorizedrepresentative, which will be delivered via certified mail, or ACH electronic deposit.

5. That the Unit listed above is not receiving any other form of government assistance for the same months of rentfor which this assistance is requested, including tenant-based voucher assistance and project-based assistance, andthe Unit is not public housing.

COMMUNITY DEVELOPMENT

*Total eligible months are subject to prior assistance, up to 11-months in arreas with at least one month current.

3. Is Owner an Individual or Sole Proprietor? No Yes If yes, must provide photo ID with W-9

Must Attach Leasing Agreement between Owner & Landlord/Agent

Check if NEW Move-InNew Move-In eligible for deposit, application feeand first- 3 months rent for housing stability.

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EMERGENCY RENTAL ASSISTANCE PROGRAM LANDLORD FORM AND CERTIFICATION

Page 2 of 3

6. That the Property is not owned by a Unit of Local Government or public agency, including but not limited to a City,County, State, Public Housing Authority, Council of Governments Housing Finance Agency, or Local Mental HealthAuthority or that if it is owned by such entity the name of such entity is noted here: .

7. Landlord/ Property Owner will not seek to obtain other assistance for the same Unit listed above and for the samemonths of rent or rental arrears covered by this assistance, that to the extent any such assistance is received, arepayment of this assistance will be repaid to the Administrator within 10 calendar days.

8. Landlord has not previously received, nor (provided Landlord actually receives rental assistance under thisprogram) will apply to receive, rental assistance funded with Coronavirus Relief Act funds that are for the sameperiod, that, including this assistance, will exceed maximum allowed in total for this Unit occupied by this Tenant orfor any other Unit for this Tenant.

9. That Landlord/ Property Owner has attached a copy of the Tenant’s lease to this form, certifies the informationprovided above regarding the terms of the lease with the Tenant named above and rent amount are true andaccurate, that all months requested above are included in lease attached, and that prior lease is attached if requestingmonths prior to lease renewal.

10. That if the written lease or oral agreement is expired or will expire during period covered by this assistance, Landlord/ Property Owner will enter into a new written lease or extend the current lease with Tenant for a monthlypayment amount no greater than the monthly amount for the expired or expiring lease or agreement, for a timeperiod at least equal to the period covered by the rent assistance. The new lease may not increase or impose otherfees or charges not allowed under the current lease or oral agreement with the tenant, including but not limited topet rent or trash pick-up. The Landlord may continue to charge all costs, expenses, and fees including but notlimited to utility charges if allowed under the original lease.

11. That if there is any portion of the rent or rental arrears that is to be paid by the Tenant or on behalf of the Tenant(Tenant Payment), Landlord confirms receipt of such payment or forgiveness for the portion of rent or rentalarrears. Landlord/ Property manager agrees to provide a 12-Month Rent Payment History.

12. The Landlord agrees to notify the City within 24 hours of tenant vacating property and to reimburse the City any timefor which rent was applied, and during which time the tenant no-longer occupied the property.

13. That late fees and penalties for nonpayment of rent or any other costs, which are not listed on the lease, up until theexpiration of the time period covered by the rental assistance actually received by Landlord for the above-namedTenant have been or will be discharged upon payment from Administrator, including accrued court costs.

14. That the Landlord agrees to not seek eviction of the above named Tenant and will cease existing eviction processesduring the application processing period and for the expiration of the time period covered by the rental assistance.

15. That the Landlord hereby releases the tenant from payment liability for any rent for the time period covered bythe assistance actually received by the Landlord, as well as any fees related to that rent. The Landlord will not evictthe tenant for any reason that predates the acceptance of the funds or for any reason related to rent or fees during thetime period covered by the funds and will not evict the Tenant for a monetary default during the time periodcovered by the rental assistance actually received, except for actions or breaches of the lease that are related tocriminal activity, property damage or physical harm to others. Nothing in this certification shall waive a Landlord’sright to file an eviction based on a non-monetary default that occurs after the expiration of the time periodcovered by the rental assistance actually received.

16. Landlord acknowledges that all information collected, assembled, or maintained by Administrator pertaining to thisContract, except records made confidential by law or court order, are subject to the Texas Public Information Act(Chapter 552 of Texas Government Code) and must provide citizens, public agencies, and other interested parties with reasonable access to all records pertaining to this Contract subject to and in accordance with the Texas PublicInformation Act.

Initial by each:

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EMERGENCY RENTAL ASSISTANCE PROGRAM LANDLORD FORM AND CERTIFICATION

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Warning: Title 18, Section 1001 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency in the United States as to any matter within its jurisdiction.

Signature of Owner, Landlord, or Agent Date

CITY OF LUBBOCK COMMUNITY DEVELOPMENT DROP-BOX: 1708 CRICKETS AVE.

Mailing Address: PO Box 2000, Lubbock TX 79457 Main Number: (806) 775-2296

Web: mylubbock.us/communitydevelopment

17. Landlord/Property Owner agrees to provide a 12-MONTH Rent Payment History, which must include any missedpayment and any credits to the account. If tenant residency is less than 12-months, provide history from move-in date.

18. Landlord/ Property Owner is requesting rent assistance for rental arrears and current month due, including alleligible fees. Application fee and deposit for New Move-In plus first 3-months may be requested, if applicable.

19. Landlord/ Property Owner shall provide the U.S. Department of Health and Human Services or U.S. Department ofHousing and Urban Development, as applicable based on the funding source of the assistance, the U.S. Inspector General,the U.S. General Accounting Office, the Texas Comptroller, the Texas State Auditor’s Office, the Office of CourtAdministration and the Texas Department of Housing and Community Affairs, or any of their duly authorizedrepresentatives, access to and the right to examine and copy records related to a payment made as a result of thiscertification.

20. That if the Owner is a different legal entity than the Landlord, that Landlord or Landlord’s Agent certifies it has thelegal authority to enter into this agreement, and that if an Agent is executing this form that documentation of agency isattached including a leasing agreement between the Owner and Landlord/Agent.

21. Notwithstanding anything to the contrary in this certification, the Landlord shall have the right to terminateparticipation in the program at any time prior to receiving assistance.

22. During this process the Owner, Landlord, or Agent agrees not to harass, confront or intimidate CommunityDevelopment or City of Lubbock staff at any time and understand this application will be processed in order received, andstaff with administering agency will contact the Owner, Landlord or Agent, as needed, if any additional information isrequired or when application is approved.

23. That the age of the unit in the property has been accurately disclosed above, and Landlord acknowledges that if theyear of construction has been represented to be after 1978, and is subsequently found to have been constructed prior to1978, the assistance provided may be subject to repayment.

24. Landlord/ Property Owner agrees to a Housing Quality Standards (HQS) inspection and further agrees to complywith Lead-Based Paint requirements, unless able to provide source documentation of recent inspection of the property,which must meet minimum HQS guidelines.

25. That the information provided is true, accurate, and complete, and if requested, Landlord is able to provide furtherdocumentation to support any representations.

26. For Individuals/Sole Proprietors of rent property's, a PHOTO ID must be submitted with the W-9 along with a leasingagreement with the Landlord/Agent, if applicable.

Initial by each:

OWNER/AGENT

ADDRESS:

TENANT(S) NAME:

PROPERTY ADDRESS: UNIT #:

Tenant InitialProperty

Owner/Agent Initial

MONTH/YR

DUE FOR

MONTH LATE FEE

OTHER FEES

(PER LEASE) TOTAL DUE AMOUNT PAID BALANCE PAID BY

Date

Date

By signing below, I agree that I have read and understood the notice above and I certify all information provided herein is true and correct to the best of my

knowledge. I further understand that the City may request additional documentation and that providing incorrect or questionable information may result in

program denial.

Charges/ Fees listed below must also be included in lease agreement.

CITY OF LUBBOCK EMERGENCY RENT ASSISTANCE- 12-MONTH TENANT LEDGER

Property Owners/ Agents may use this form to complete a tenant ledger. This form must be completed, initialed and signed by both the Property Owner/ Agent. Any

charges or eligible fees must be included in the lease. Any charges that do not reflect the lease will cause for application to be denied. Partial payments must be applied

toward balance due.

NOTICE TO LANDLORD/OWNER & TENANT: It is a criminal offense to accept funds or apply for assistance for ANY PERIOD of time in which a tenant is not

residing in property or vacates prior to end of Lease. Any funds received after a tenant vacates property must be returned IN FULL. Under Title 18,Section

1001 of the United States Code, failure to comply may leave you subject to fines, imprisonment or both. Such offenses will be reported to Federal and

State Authorities.

Authorized Signature- Owner/ Agent

Tenant Name/ Signature

OWNER/ AGENT PHONE #:

Maximum Late Fee/ Month (per Lease):

Least Start Date/ Move-In Date:

Lease Termination Date/ Move-Out Date:

Monthly Rent Charge Per Lease/ Contract:

COMPANY/ OWNER NAME:

Late Fees will be Assessed Beginning:

This form may be used if you do not have a ledger format or program in place. This must be completed in full and all signatures/ initials must be original.

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Form W-9(Rev. August 2013)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

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2.

Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification:

Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Other (see instructions) ▶

Exemptions (see instructions):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Requester’s name and address (optional)

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

Employer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal RevenueService (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below), and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. The IRS has created a page on IRS.gov for information about Form W-9, at www.irs.gov/w9. Information about any future developments affecting Form W-9 (such as legislation enacted after we release it) will be posted on that page.

Purpose of FormA person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, payments made to you in settlement of payment card and third party network transactions, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the

withholding tax on foreign partners’ share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct.

Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

• An individual who is a U.S. citizen or U.S. resident alien,

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,

• An estate (other than a foreign estate), or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

Cat. No. 10231X Form W-9 (Rev. 8-2013)

REQUIRED- TO BE COMPLETED BY PROPERTY OWNER OR LEGAL AUTHORIZED AUTHORITY

Direct Deposit Authorization SE

CTI

ON

1

Transaction Type

New setup (Sections 2, 3, 5 and 6) Change financial institution (Sections 2, 3, 4, 5 and 6)

Change account type (Sections 2, 3, 4, 5 and 6)

Cancellation (Sections 2 and 6 - Sections 7 and 8 for city use)

Change account number (Sections 2, 3, 4, 5 and 6)

SEC

7

Cancellation by City of Lubbock (for city use) Reason Date

SEC

5

International Payments Verification (required)

Will these payments be forwarded to a financial institution outside the United States? ......................................................... YES NOIf "YES," also complete the ACH (Direct Deposit) Payment Destination Confirmation Form.

Authorization for Setup, Changes or Cancellation (required)

SEC

TIO

N 6

Authorized signature Printed name Date

I authorize the City of Lubbock, TX to deposit my payments from the City of Lubbock to my financial institution electronically. I understand that the City of Lubbock will reverse any payments made to my account in error. I further understand that the City of Lubbock will comply at all times with the National Automated Clearing House Association's rules. (For further information on these rules, please contact your financial institution.)

This form may be used by vendors, individual recipients or city employees to receive payments from the City of Lubbock by direct deposit or to change/cancel existing direct deposit information.

Signature Date

Phone number

Employee Name

Comments

Authorized Signature (for city use)

SEC

TIO

N 8

City of Lubbock Accounts Payable Department P. O. Box 2000Lubbock, TX 79457

FAX: 806-775-3273 Phone: 806-775-2150

Please return your completed form to:

ext.

Financial institution name City State

Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account

Checking SavingsFinancial representative name (optional) Title (optional)

Financial representative signature (optional) Phone number (optional) Date (optional)

New Account Information (Setups and Changes) (Completion by financial institution is recommended.)

SEC

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N 3

ext.

Payee name Phone number

Mailing address City State ZIP code

Payee Identification

SEC

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N 2

Individual Taxpayer Identification Number (ITIN) City employee Vendor or other recipient

ext.

Taxpayer Identification Number (TIN) Employer Identification Number (EIN) Social Security Number (SSN) *

Payee type

Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account

Checking Savings

Existing Account Information (Changes Only)

SEC

4

OPTIONAL

Instructions for Direct Deposit AuthorizationYou have certain rights under Chapter 552, Government Code, to review, request and correct information we have on file about you. To request information for review or to request error correction, use the contact information on this form.

Section 1: Transaction Type

Section 2: Payee Identification

Section 6: Authorization for Setup, Changes or Cancellation

Section 5: International Payments Verification

Section 7: Cancellation by City of Lubbock

Section 8: Authorized SignatureFor city use only.

Provide reason for cancellation request.

For City Use

Must be completed in its entirety, and no alterations to the authorization language will be accepted.

Check "YES" or "NO" to indicate if direct deposit payments to the account information designated in Section 3 of this form will be forwarded to a financial institution outside the United States. If "YES," also complete the ACH (Direct Deposit) Payment Destination Confirmation Form.

Section 3: New Account Information (Needed for setups and changes)

Completion by financial institution is recommended.

Important: Your direct deposit account information may be different from the account information printed on your checks. It is recommended that you contact your financial institution to confirm your direct deposit account information.

Select payee type, provide the Taxpayer Identification Number (TIN), Employer Identification Number (EIN) Social Security Number (SSN)* or Individual Taxpayer Identification Number (ITIN) and enter payee contact information. *Federal Privacy Act StatementDisclosure of your Social Security number is required and authorized under law, for the purpose of tax administration and identifica-tion of any individual affected by applicable law, 42 U.S.C. sec. 405(c)(2)(C)(i); Texas Govt. Code Sections 403.011, 403.056, and403.078. Release of information on this form in response to a public information request will be governed by the Public InformationAct, Chapter 552, Government Code, and applicable federal law.

Select the appropriate transaction type(s).

Section 4: Existing Account Information (Needed for changes to existing account information)

When requesting a change to your existing direct deposit account information, you must complete Section 4 with the existing account information for verification purposes. This measure will help the city verify accuracy of the requested change.

EMERGENCY RENTAL ASSISTANCE PROGRAMLANDLORD/ OWNER PAYMENT FORM AGREEMENT

DATE: PROPERTY OWNER/ MANAGER:

PROPERTY ADDRESS: UNIT:

TENANT NAME(S):

The COVID-19 pandemic has placed severe financial stress upon residents of the City of Lubbock. Due to the COVID-19 outbreak, TENANT is unable to pay rent and other charges. As a result, and based upon TENANT’S individual finances, health, and other circumstances, Rental Assistance has been requested for past-due rent or collectible rent, where such non-

payment was a result of the COVID-19 outbreak and occurred on or after April 1, 2020.

MONTH TOTAL

TOTAL PAYABLE BY THIS AGREEMENT: PAYABLE TO:

ADDRESS:

/ Print Name

PROPERTY OWNER/ MANAGERDATE

CITY OF LUBBOCK/ COMMUNTIY DEVELOPMENT DATE APPROVED/ RECEIVED

UTILITY FEE/ *OTHERNOT ELIGIBLE: Fees/ Penalties NOT listed on Lease; Court Fees due to Eviction Cases; Deposits for moving units within same complex Eligible/Other may include Garbage, Parking, Utilities (current due only), or other fees as described on lease.

Check here if Name below is different than Owner shown on W-9. Must provide agreement with owner and property manager/agent/landlord

NAME:

CITY, STATE ZIP:

By signing below, I certify that I am an authorized agent, owner, or property manager of Property Address listed above:

RENT DUEEnter Total Rent Due (including fees). This must match lease/ rent agreement. If tenant receives Section 8 or other assistance, only their portion is eligible.

Original Signature or Electronic Signature Required

Rent Due plus any Eligible Fees

MONTH(S) Must Include: Prior Months (max 11) Current Month Due Assistance is limited to 12-months per applicant/ household/ person, regardless of address or unit number. Future Months considered for housing stability

2345

67

8

9

11

12

10

1

*Tenants may reapply as needed, subject to program funding and limitations.

Include New Move-In Fees if applicable

NEW Move-In- Limited to first 3-months of Rent Payments plus Application Fee and Deposit for Housing Stability.

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Check Here if NEW Move-In

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Application Fee:

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Deposit:

Phone:

Unit #:

Please read each statement below and initial beside each.

1.

2.

3.

4.

5.

6.

Community Development DepartmentHQS Inspection and Agreement

Property Owner/ Manager:

Property Address:

Inspection Date:

I am the Owner/ Manager or Authorized Representative of the Property above.

I understand the current tenants of the Property has made a written application to the City of Lubbock, Community Development Department for rental assistance under the COVID-19 Emergency Rental Assistance Program.

I understand that Community Development will send a certified Housing Quality Standards (HQS) Inspector to inspect the property.

I certify that any parts of the Heating or Cooling system that may be on the roof or in the attic space are in decent, safe and proper working condition.

or Authorized Representative

I/We give permission for the HQS Inspector to enter the Property and perform all necessary inspections.

I agree that myself or an authorized representative will be present at the Property while the inspection is to be performed.

Property Owner/ Manager HQS Inspector

If you are unable to print these pages, you agree by typing your name, you are signing this application electronically and you further agree that your electronic signature is the legal equivalent of your manual signature.

REQUIRED: To be completed and signed by Property Owner/ Manager

EMERGENCY RENTAL ASSISTANCE PROGRAM TENANT APPLICATION

CITY OF LUBBOCK COMMUNITY DEVELOPMENT RENT ASSISTANCE

a

Administrator Name : CITY OF LUBBOCK COMMUNITY DEVELOPMENT

A. APPLICANT INFORMATION

1. Applicant(s) Name(s):

2. Street Address:

3. City/State:

6. Phone:

8. Property Mgr/Owner Name:Contact Information (Phone Number & Email):

9. Housing Authority/ Section 8:Do you live in a public housing unit operated by a Housing Authority or receive a Section 8 voucher?

No Yes If Yes, you MUST provide notice from Housing Authority that you are not eligible for adjustment under their program. If you receive Section 8, you must provide documentation showing total rent you are required to pay.

B. FOR TEXAS EVICTION DIVERSION PROGRAM CASES ONLYCourt Docket #: Justice of the Peace (J.P.) Precinct # in Lubbock County

C. UNIT AND CONTRACT RENT INFORMATION

1. Period of Lease: to

2. Unit Size - Number of bedrooms in the Unit:

3. Unit Rent: $


7. Email:

If Lease expires, will you remain in the unit on month-to-month? Yes NoIf No

This MUST match Lease Agreement. If you receive housing assistance, you must prportion. You must show documentation from requests. Failure to provide this will disqualify

4. Zip Code 5. Unit #:

Page 1 of 6

, Date Expected to Vacate:

ovide documentation showing your Housing Authority of any adjustments or you from the program.


CITY OF LUBBOCK COMMUNITY DEVELOPMENT RENT ASSISTANCE Page 2 of 6

D. NEEDS ASSESSMENT

b. If, yes, what is the total amount of rental assistance already received?

1. 1. Amount Owed to Landlorda. Total amount of rent currently owed to your landlord: $

Include past due or partial payments for rent arrears owed.b. List the prior months for which rent is owed:

Include both month and year. For example: 10/2020, 11/2020 and 12/2020.

c. List the current month for which you are seeking rental assistance: Note that prior months and current month due cannot exceed 12 months.

*You may reapply for additional assistance, depending on available funding and prior assistance.

2. Housing Assistance Received- Duplication of Benefitsa. Have you received any rental assistance from other sources (for example, from the City, County,

church or other organization) for the months that you are seeking rental assistance?No Yes

If no, skip the rest of this question.

Month(s) the rental assistance covered:

What was the source of assistance (for example, name of assistance program)?

3. Unmet NeedWhat is your total unmet need?Calculate the total amount of rent currently owed to your landlord (item 1a) minus (-)total amount of rental assistance already received (item 3b).

*See Warning Below*

I/We Certify that I/we have read and understand the above Warning and further certify that I/we have not received, nor will apply to receive rent assistance for the same period of months requested above from any other source.

Applicant Name- Print/Sign (Required) Co-Applicant Name- Print/ Sign (Required)

4. CERTIFICATION OF NON-DUPLICATION OF BENEFITSWARNING: If you have applied, will apply or have received payments for rent assistance which covers the same period of months requested above, you are committing fraud. Such action will be reported and is punishable by fines, imprisonment or both.TITLE 18, SECTION 1001 of the United States Code: (1) makes it a violation of federal law for a person to knowingly and willfully (a) falsify, conceal, or cover up a material fact; (b) make any materially false, fictitious, or fraudulent statement or representation; OR (c)make or use any false writing or document knowing it contains a materially false, fictitious, or fraudulent statement orrepresentation, to any branch of the United States Government; and (2) requires a fine, imprisonment for not more than five (5)years, or both, which may be ruled a felony, for any violation of such Section.

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DEMOGRAPHIC INFORMATION:The information below is requested for reporting purposes only. You may not be discriminated against on the basis of this information you provide.

Ethnicity Codes: H – Hispanic: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Terms such as “Latino” or “Spanish Origin” apply to this category.

NH – Not Hispanic

2. Asian3. Black or African American4. Native Hawaiian or Other PacificIslander5. White6. Multi/Other:

Age Codes: A. 0 – 17 yearsB. 18 – 24 years C. 25 – 61 years D. 62 years +

Disability Status: A person with a disability has a physical or mental impairment which substantially limits one or more major life activities; a record of such an impairment; or is regarded as having such an impairment. The definition of disability does not include current, illegal use of or addiction to a controlled substance.

Household MemberFull Name

Ethnicity Code

H/ NH Race Code Age Code

Check if Person is Disabled

Date of Birth

GenderM/F

1.

2.

3.

4.

5.

6.7.

8.

9.

10.11.

12.

13.

Choose All Applicable Race Codes: 1. Alaskan Native/ American Indian



HOUSEHOLD COMPOSITION INFORMATION (List all members of the household)

Full Name (exactly as it appears on driver’s license or other

identification document)

Relationship to Head of Household

Student Status Receives Income?

Check if Veteran

1. Applicant/

Head of Household

Full Time

Part Time N/A Yes

No

2. Spouse Co-Head

Dependent Other Adult FT PT N/A Yes

No

3. Spouse Co-Head

Dependent Other Adult

FT PT N/A Yes

No

4. Spouse Co-Head


FT PT N/A Yes

No

5. Spouse Co-Head


FT PT N/A Yes

No

6. Spouse Co-Head


FT PT N/A Yes

No

7. Spouse Co-Head


FT PT N/A Yes

No

8. Spouse Co-Head


FT PT N/A Yes

No

9. Spouse Co-Head


FT PT N/A Yes

No

10. Spouse Co-Head


FT PT N/A Yes

No

11. Spouse Co-Head


FT PT N/A Yes

No

a. Is any household member listed above a foster child? No Yes, who?

b. Is any household member listed above a live-in attendant? No Yes, who?

G. CATEGORICAL ELIGIBILITY

Is the household made up of 6 or fewer members AND receiving benefits under SSI (for the head or co-head of household), LIHEAP, or SNAP?

If yes, attach SNAP AWARD LETTER and/or SSI Award LetterYou still MUST COMPLETE EMPLOYMENT Section, and provide Pay Stubs or other income information

for All Household Members.

If Yes, Source?(Job, SSI,

Unemployment, etc.)



INCOME & EMPLOYMENT INFORMATION: Complete only for Household Members 18-years and older. Add an additional sheet if you need space to list the income of additional household members. Complete only areas applicable to each household member who is or was employed.

YOU MUST INCLUDE INCOME DOCUMENTATION FROM ALL SOURCES, as applicable.>Social Security, Disability, Retirement, VA Benefits, SSI >Pay Stubs, Cash Payments, Self-Employment, etc.>Child Support, Adoption/Foster Payments, Alimony, etc. >SNAP, TANF, Cash Assistance, other financial help>Unemployment Notice and Payment History or Status >Notice of Termination/ Hours Reduced, etc.

1. Household Member Name:

Occupation:

Employer/ Business Name and City:

Date Hired:

Salary:

$

Pay Period: Hourly Weekly Bi-weekly (26)

Semi-monthly (24) Monthly Annually Other

Current Hours/ PP: Prior Hours/ PP:


Occupation:

Salary:

$




Occupation:

Salary:

$




Occupation:

Pay/ Hour:

$

Salary:

$



Date Terminated:(if applicable)

Pay/ Hour:

$

Currently Employed? Yes No

Receiving Unemployment? Yes No

Reason for cut hours or termination:



Pay/ Hour:

$


Date Hired: Date Terminated:(if applicable)







Pay/ Hour:

$






Reason for cut hours or termination:Re



Required by ALL Applicants- Include All Sources of Income (See Examples Above)


Page 6 of 6

RELEASE AND SIGNATURESEach of the undersigned Applicants for the Texas Emergency Rental Assistance Program (TERAP) hereby certifies that all of the information provided in the above Application is true and correct, and does hereby authorize the release and/or verification of employment, tenancy, and income information.

_____________________________________ _______________________________________ ________________________ Applicant’s Printed Name *Signature Date

_____________________________________ _______________________________________ ________________________ Co-Applicant’s Printed Name Signature Date


Reasonable accommodations to complete the application will be made for persons with disabilities and language assistance will be made available for persons with limited English proficiency.

CITY OF LUBBOCK COMMUNITY DEVELOPMENT DROP-BOX: 1708 Crickets Ave

Mailing Address: PO Box 2000, Lubbock TX 79457 Main Number: (806) 775-2296

Web: mylubbock.us/communitydevelopment

INCOME & EMPLOYMENT INFORMATION- Continued...Add an additional sheet if you need space to list the income of additional household members.


Occupation: Date Hired:

Pay/ Hour:

$

Salary:

$




Occupation:

Pay/ Hour:

$

Salary:

$



Date Terminated:(if applicable)

Currently Employed? Yes

Receiving Unemployment? Yes

Currently Employed? Yes

Receiving Unemployment? Yes








No

No

No

No

*IF APPLICATION SUBMITTED BY PROPERTY OWNER/ MANGER, ORIGINAL SIGNATURES FROM THE TENANT ARE REQUIRED

Page 1 of 2

INSTRUCTIONS: This is a written statement from the program beneficiary that will serve as documentation that they meet the definition of having No Annual Income or that does not exceed the applicable limits for the Emergency Rental Assistance Program. 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.

Definition of Income: Select the ONE appropriate definition. If none, move on to Applicant Information. This certification is only allowable for the two options listed below. My household lives in a rent-restricted property and has provided an income certification from the property manager/ owner, AND my household’s Annual Gross Income is less than 80% of the Area Median Income.

My household’s Annual Gross Income is below 60% of the Area Median Income. (You must provide SNAP, SSI, etc.)

Member Information Mark with an X, all the applicable categories. HH = Head of Household; CH = Co-Head of Household; PT≥18 = Part-time student age 18 or over; FS≥18 = Full-time student age 18 or over; <18 = Child under the age of 18 years

First and Last Name

HH CH PT≥18 FS≥18 <18 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Income Information Annual gross income (total of all members) = $

Certification I/we certify that this information is complete and accurate. I/we agree to provide documentation on all income sources to the HUD Grantee/Program Administrator.

YOU MUST COMPLETE SIGNATURES ON NEXT PAGE

APPLICANT INFORMATION: Required for all Applications

1. Applicant Name:

2. Street Address:

3. City/State/Zip Code: 4. County: Lubbock

5. Email Address: 6. Phone:


Emergency Rental Assistance Program

Page 2 of 2

Emergency Rental Assistance Program Self-Certification of Annual Income by Beneficiary

I/we certify that this information is complete and accurate. I/we agree to provide, upon request, documentation on all income sources to the HUD Grantee/Program Administrator.

HEAD OF HOUSEHOLD Signature Printed Name Date

OTHER BENEFICIARY ADULTS* 1. Signature Printed Name Date

2. Signature Printed Name Date










* Attach another copy of this page if additional signature lines are required.

WARNING: The information provided on this form is subject to verification by HUD, the Texas Department of Housing and Community Affairs or the program administrator 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.

*IF APPLICATION SUBMITTED BY PROPERTY OWNER/ MANGER, ORIGINAL SIGNATURES FROM THE TENANT ARE REQUIRED

EMERGENCY RENTAL ASSISTANCE PROGRAM TENANT CERTIFICATION

Tenant Name(s):

Property Address:

Tenant Phone #:

Tenant email:

Unit Number:

I/We, above named Tenant(s), hereby certify that:

1. I/We have occupied the above-referenced unit as my/our principal residence during the period of time forwhich the rental arrears assistance, if any, is requested and will occupy the unit as my/our principal residence throughout the remaining months for which the assistance is provided.

2. I/We understand that this program requires participation from both the Landlord and Tenant and if theLandlord does not elect to participate, no assistance will be provided.

3. To my/our knowledge, the Unit for which I am receiving assistance is not public housing and is not receivingany other form of government assistance for the same month or months of rent for which this assistance isrequested, such as tenant-based voucher assistance (such as Section 8), or project-based assistance.

4. I/We will not seek to obtain rental assistance in the future for the same months of rental arrears or rentcovered by this assistance, and that if I/we do receive such assistance I will report it to Landlord using thecontact information in my/our lease, and to the Administrator using the contact information at the top ofthis form.

5. I/We will inform the Administrator, using the contact information at the top of this form, within ten calendardays if evicted from the Unit or if I/we no longer occupy the Unit as my/our principal residence during theperiod of assistance.

6. To my/our knowledge, neither I/We, nor the Landlord, have previously received rental assistancefunded with State or Federal funds for any months requested on this application.

7. I/We have provided a written lease to Administrator and that the information I have provided in the TenantApplication correlates with the the terms of my/our lease and rent amount are true and accurate and ifrequested, I will provide additional proof of my/our tenancy.

8. I/We understand that in accordance with Section 2105.151 of the Tex. Gov't Code, I/we have a right torequest a hearing if I/we believe the Administrator has been unjust, discriminatory, or without reasonablebasis in law or fact, and that I/we have the right to file a complaint with the Texas Department of Housingand Community Affairs, U.S. Department of Housing & Urban Development, and/or the U.S. Department ofTreasury.

9. I/We have been impacted by the COVID-19 Pandemic. (Please select any/all conditions thatapply to your household since April 1, 2020):A. Household has had a loss or reduction of income due to the COVID-19 pandemic.B. Household has had increased household costs due to school closures or medical expenses associatedwith the COVID-19 pandemic.


10. The information I/We have provided is true, accurate, and complete, and if requested, I am able to provideadditional documentation to prove my household’s loss of income or additional expenses.

11. Tenant acknowledges that all information collected, assembled, or maintained by Administrator pertainingto this Certification, except records made confidential by law or court order, are subject to the Texas PublicInformation Act (Chapter 552 of Texas Government Code) and must provide citizens, public agencies, andother interested parties with reasonable access to all records pertaining to this Contract subject to and inaccordance with the Texas Public Information Act.

12. Tenant shall provide the U.S. Department of Housing and Urban Development, the U.S. Inspector General,the U.S. General Accounting Office, the Texas Comptroller, the Texas State Auditor’s Office, the Office ofCourt Administration and the Texas Department of Housing and Community Affairs, or any of their dulyauthorized representatives, access to and the right to examine and copy records related to a payment madeas a result of this certification.

13. I/We have made a copy of this application for my/our records. The City will not provide copies.

14. I/We may remain responsible for charges authorized under the lease going forward, including any fees nototherwise eligible under program and I/we understand that rent assistance will not alter or affect lease.

Reasonable accommodations will be made for persons with disabilities and language assistance will be made available for persons with limited English proficiency.

CITY OF LUBBOCK COMMUNITY DEVELOPMENT DROP BOX: 1708 Crickets Ave.

Mailing Address: PO Box 2000, Lubbock TX 79457Main Number: (806) 775-2296 Web: mylubbock.us/communitydevelopment

*Signature of Head of Household Date

Signature of Co-Head/Spouse Date

Signature of City of Lubbock Staff Person Date


Describe your financial impact due to the Coronavirus pandemic including circumstance(s) resulting in loss of income or increased expenses. Include date(s) of loss, special circumstances of why loss occurred, description of increased expenditures and explain how your household is attempting to recover financially (i.e. currently seeking employment, started a new job, temporary employment, budgeting to decrease living expenses, etc.)

REQUIRED- You may use separate sheet and attach to application.

ORIGINAL SIGNATURES FROM THE TENANT ARE REQUIRED