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COVID-19 Rental and Utility Assistance Application

2. Lancaster County - Villages and Townships
   Covid-19 Rental and Utility Assistance
   The Emergency Rental Assistance assists households that are unable to pay rent and utilities due to the COVID-19 pandemic. Landlords and tenants are eligible to apply.
   
   Eligibility: An “eligible household” is defined as a renter household in which at least one or more individuals meets the following criteria:
   *You, or an adult member of your household, has had a loss of income due to COVID-19;
   *You have an unpaid rent balance that began on or after March 13, 2020;
   *Must not duplicate other federal, state, or local assistance; and
   *Your household income before March 13, 2020 was less than the below:
   
   

   Family Size:	Income Limit:
   1	$46,000
   2	$52,600
   3	$59,150
   4	$65,700
   5	$71,000
   6	$76,250
   7	$81,500
   8	$86,750

   
   
   Available Assistance:
   *Rent Assistance: Up to 12 months of rent assistance dating back to March 13, 2020.
   *Utility Assistance: Electricity, gas, water and sewer, trash removal and energy costs, such as fuel oil.
   *Telecommunication services (telephone, cable, Internet) delivered to the rental dwelling are not considered to be utilities.
   
   Please be prepared to provide:
   *Documentation in the form of a 1040, wage statement or unemployment statement for income verification for at least the two months prior to the submission of the application.
   *Copies of invoices for back rent and/or utilities owed.
   *Attestation a reduction in income or significant costs were incurred related to Covid-19.
4. Covid-19 Rental and Utility Assistance Application
6. Last Name
7. First Name
9. Date of Birth
10. Last 4 of SSN
12. Address
14. City
15. State
    Nebraska
16. County
    Lancaster
17. Zip Code
19. Phone Number
20. Email
22. Gender

    1. Male

    1. Female
24. What kind of help do you need? Check all that apply.
26. Rental Assistance:

    (Up to 12 months of rent assistance dating back to March 13, 2020.)

    1. Behind in Rent/Arrears

    1. Security Deposit

    1. First Month's Rent
28. Utilities Assistance:

    (Utilities that are covered by the landlord within rent will be treated as rent.)

    1. Electricity

    1. Gas

    1. Water/Sewer
30. Household Total Annual Gross Income $
    (Household income is determined as either the household’s total income for calendar year 2020 or the household’s monthly income at the time of application.)
32. Marital Status:

    1. Single
    2. Married
    3. Divorced

    1. Legally Separated
    2. Widowed
34. Housing Information:
36. How much rent do you pay a month?
37. How much do you currently owe in rent?
39. Landlord Information:
41. First Name
42. Last Name
44. Landlord Address
46. City
47. State
48. Zip Code
50. Landlord Phone Number
51. Landlord Email
53. Best way to get in touch with your Landlord:

    1. Mail

    1. Phone

    1. Email
55. Do you rent month-to-month or do you have a Lease?
56. If you have a Lease, when did it start?
57. When does it end?
59. Did you pay a security deposit?

    1. Yes
    2. No
60. How much did you pay?
62. Loss of Income:
64. If you lost income because of COVID-19, please explain circumstances:
66. COVID-19 Income Loss Confirmation

    Please acknowledge that by checking this box, you have qualified for unemployment benefits or you experienced a reduction in income, incurred significant costs, or experienced other financial hardship due directly or indirectly to COVID-19 that threaten the household’s ability to pay the costs of the rental property when due.

    1. Yes
68. Income and Housing Attestation Due to COVID 19
    I hereby certify that the information given is complete and accurate to the best of my knowledge. I understand that I may be required to present documentation showing that I am at risk of experiencing homelessness or housing instability. This may include past due rent and utility notices and eviction notices, if any, as part of the application process.
    
    By typing my name in the applicant signature field, I indicate that I am the named person, and this entry is the legal equivalent of a manual/handwritten signature. I further understand that I can request a copy of this form to print and sign.
70. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
72. Electronic Signature
Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field