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City of San Dimas COVID-10 Emergency Rental Assistance Program APPLICATION

The City of San Dimas in partnership with the Los Angeles Development Authority (LACDA) is offering an Emergency Rental Assistance Program funded by the CDBG-CARES Act and is designed to assist eligible residents, impacted by the COVID-19 Pandemic. The program will be open to individuals whose households’ income has been reduced as result of COVID-19 and that are not receiving rental assistance through other organizations. Applicants will be required to provide documentation of their hardship.

The program is expected to serve as many households as possible, with an average grant amount of $500 per household per month, for not more than three (3) months. Priority assistance is provided to the neediest residents and not on a first come first serve basis. If funds are fully expended, eligible applicants will be placed on a wait list and be notified if additional funding becomes available.

Participants must live within the City of San Dimas and have a maximum household income at or below 80% of the area median income (AMI) for Los Angeles County.

Program Guidelines:  The program is designed to benefit low to moderate income households impacted by COVID-19.  Residents in Mobile parks are eligible if you cannot pay your space rent.  Priority will be given to families with children and lower income earning households. Consideration may be given to other vulnerable populations.  Eligible tenants will have the grant paid to the landlord directly, benefiting the tenant and the landlord.  Must communicate with your landlord and let them know that you are applying for assistance and provide the landlords contact information and email.  The rent must be considered current by the landlord after receipt of the grant payment.  The grant will be calculated based on the amount of rent owed and the tenant’ ability to pay a portion of the past due rent.  Applicants will be required to provide documentation of their income and eligibility which may include check stubs, bank statement and/or a letter from your employer. Alternate documentation may be considered for individuals whose income was based on cash compensation.  Documentation must show an impact on their employment or income beginning March 10, 2020 or that is attributed to the COVID-19 pandemic.

Examples of Impact by COVID-19 (not limited to the following):  Job loss, furlough or layoff  Reduction in hours of work or pay  Store, restaurant or office closure  to miss work to care for a home-bound, school age child or elderly person

Instructions: Please complete and return the attached checklist and application along with the Supplemental Worksheets. All forms must be completed in full.

Copies of recent documents as indicated on the attached Program Checklist must be submitted with your application. Mail your application: City of San Dimas 245 E. Bonita Avenue San Dimas, CA 91773 Attn: Ann Garcia Housing and Special Projects (909) 394-6282

City of San Dimas COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM CHECKLIST

The following documents are required in order to determine your program eligibility. Please check all boxes that apply and attach copies of applicable documents to your application and submit them along with the Program Application and Supplemental Worksheets. All forms must be completed in full.

Documentation Required: Types of Verification Copy of current ’s license or CA Identification Proof of Age Card Employment Proof of employment / Loss of employment 2019 Tax return(s) OR Two (2) months paystubs from Proof of Income for everyone in the household most recent job for everyone in the household Rental Occupant Copy of your rental agreement Sign & Dated “Release of Information” with landlord’s Release of Information Approval name and information Copy of most recent utility bills. (do not include phone, cable or satellite TV bills) You can include Monthly Utility Costs service if you have a school age or college student at home and if you are working from home.

CERTIFICATION

I certify that I am providing the above information documentation as part of this application and is true and accurate.

______Applicant’s Signature Date Applicant’s Signature Date

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SAN DIMAS - APPLICATION COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM

The information you supply on this questionnaire will determine your eligibility for the COVID-19 Emergency Rental Assistance Program. All information in this form is confidential.

APPLICANT(s) (Please print in ink)

Head of Household: Name ______DOB: ______

Address: ______Household Size____

Driver’s License # ______Female Male

Telephone # (Home) ______(Cell ) ______

Rent Subsidy From Any Source (family support, public assistance) no yes $______

Current Rent Amount:______Your last rent payment (amount/month): ______

HOUSEHOLD OCCUPANTS (List head of household first) PLEASE PRINT Date of Birth Student Name Occupation (DD/MM/YYY) (Yes/No)

MONTHLY INCOME FOR ALL HOUSEHOLD MEMBERS (Attach pages if needed for each family member) Head of Household: Disability Employment $ $ Veteran’s Benefits $ Benefits Social Security $ Unemployment $ Other: $ General SSI $ $ Assistance Family Member: Disability Employment $ $ Veteran’s Benefits $ Benefits Social Security $ Unemployment $ Other: $ General SSI $ $ Assistance

AVERAGE MONTHLY UTILITY COSTS Electric Gas Water Sewer Trash Internet Total

$ $ $ $ $ $ $

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APPLICANT CERTIFICATION

I/We certify that the information provided in this application is accurate, complete to the best of my/our knowledge and belief and is subject to verification.

I/We give consent to have the City of San Dimas to obtain any information or documentation required to verify program participation.

I/We understand any attempt to obtain COVID-19 Emergency Rental Assistance by false information, impersonation, failure to disclose or other fraud is a crime under Federal law.

I/We also understand that I/we agree and are to notify the City of San Dimas, if I/we change my/our contact information or my/our financial or living conditions.

______Applicant’s Signature Date Applicant’s Signature Date

APPLICANT CERTIFICATION:

I/We understand that the COVID-19 Emergency Rental Assistance Program is designed to be emergency assistance in the form of a grant toward my/our monthly rental or space rent.

I/We further understand that I/We authorize the City of San Dimas to utilize my/our information provided in this application for that purpose.

______Applicant Signature Date Applicant Signature Date

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CITY OF SAN DIMAS COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM Landlord Program Participation Payment Acceptance Agreement

Applicant Tenant:

Tenant :

SECTION I - COMPLETED BY CITY OF SAN DIMAS STAFF

LANDLORD/LEGAL PROPERTY OWNER MANAGEMENT COMPANY (if applicable) TELEPHONE NUMBER

ADDRESS CITY STATE ZIP CODE

The City of San Dimas administers this program and has verified the lease/rental agreement and other eligibility documentation by the Applicant identified above and determined that this household is eligible to receive Emergency Rental Assistance. The City of San Dimas will issue monthly rental and/or monthly rental arrears payments directly to the landlord/property management company on behalf of eligible households economically impacted during the COVID-19 pandemic through job loss, furlough or reduction in hours or pay. This agreement and a completed W-9, Request for Taxpayer Identification Number and Certification must be completed by the landlord/property management company and returned to the City of San Dimas staff in order to process the payment(s). Payment(s) will be issued on a monthly basis to the landlord as defined below:

RENTAL ASSISTANCE PROVIDED ANTICIPATED TERMS OF ASSISTANCE

Amount $ ______For ______consecutive month beginning ______

AGENCY STAFF NAME (PLEASE PRINT) AGENCY STAFF SIGNATURE DATE TELEPHONE NUMBER

SECTION II - COMPLETED BY THE LANDLORD/LEGAL OWNER/MANAGEMENT COMPANY

The landlord (legal owner of the residence reference above) must complete this Section.

 I do not want to participate in the City of San Dimas COVID-19 Emergency Rental Assistance Program; or

 I would like to participate in the City of San Dimas COVID-19 Emergency Rental Assistance Program. To receive payment, I will provide this signed agreement a W-9 Request for Taxpayer Identification Number and Certification.

TENANT’S MONTHLY RENT IS DUE ON THE _____ OF EACH MONTH.

LANDLORD/LEGAL OWNER’S NAME/MGT. COMPANY (PLEASE PRINT) APPLICANT (TENANT) NAME (PLEASE PRINT)

MAILING ADDRESS PROPERTY ADDRESS

CITY STATE ZIP CODE CITY STATE ZIP CODE

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LANDLORD/LEGAL OWNER/MANAGEMENT COMPANY CERTIFICATION

I UNDERSTAND AND CERTIFY THAT: In no case am I entitled to a payment for a month that the applicant does not reside at my property. If I receive a direct rent payment for a month that the applicant did not reside at my property, I shall remit to the City of San Dimas an amount that represents the overpaid rent. To return such amounts or payments, I shall call the City of San Dimas at (909) 394-6282 and mail payment to City of San Dimas, 245 E. Bonita Avenue, San Dimas, CA 91773. I must not cash a direct rent payment if the applicant has moved. I may be prosecuted if I commit fraud or knowingly assist an applicant to commit fraud. If I am found guilty of committing fraud, I will no longer be entitled to receive direct rent payments. I may not acquire rights to sue [Agency] for payment of rent or for a breach of any obligations by the tenant.

I also understand and certify that I receive no other subsidy and/or assistance from or on behalf of this applicant for full or partial monthly rental payment.

Rental assistance is limited and the duration of assistance as stated in Section 1 of this agreement. The City of San Dimas will make every effort to make rental assistance payments as required by the lease agreement but will only be responsible for late fees due to administrative errors by the City of San Dimas staff. I understand that assistance may be terminated if a is determined to be no longer eligible, was never eligible, has not been fully engaged in the program, and/or has not been fully compliant with program requirements as determined by the City of San Dimas. Examples non-compliance include failure to return phone calls or e-mails and failure to disclose all income or expenses.

In addition, I understand and agree that during the term of this agreement, I must give the City of San Dimas a copy of any notice to the program participant to vacate the housing unit, or any complaint used under state or local law to commence an eviction action against the program participant.

THE LANDLORD/LEGAL OWNER/MANAGEMENT COMPANY MUST SIGN AND DATE:

LANDLORD/LEGAL OWNER/MGT. CO. NAME LANDLORD/LEGAL OWNER/MGT.CO. SIGNATURE: DATE: TELEPHONE NUMBER: (PLEASE PRINT)

PLEASE COMPLETE AND SUBMIT THE W-9 Request for Taxpayer Identification Number and Certification ATTACHED BELOW

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