COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM

Ho-Chunk Housing and Community Development Agency
COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM
Rental Assistance and Utility Assistance Application

Before you start using this online platform, please be sure to either take a picture of all required submissions. This includes a picture or electronic copy (PDF) of the following:
- Tribal ID (or other tribal member verification)
- Current Residential Lease
- Current Income Information or 2020 Federal Income Tax Return (1040 Form)
- For Rental Arrears Payments, copy of rent statement or rent ledger.
- Current Utility Bills.
Having copies of this information, prior to the start this application will aid you in completing this submission.

Applicants must submit this Form and supporting documentation for each additional month (or three-month prospective period) that they seek Financial Assistance under the ERA Program.

All applications must be completely filled out for processing to begin.
Do you rent the residence in which you are living? *

Yes No, If no, you are not eligible for Emergency Rental Assistance. Please visit HHCDA.com about additional covid assistance that you may be eligible for.
If you have checked Yes, continue filling out application. If no, you are not eligible for Emergency Rental Assistance. Please visit HHCDA.com about additional covid assistance that you may be eligible for.
Date

Month Day Year
Date
Applicant Name *
Date of Birth *

Month Day Year
Date
Tribal Enrollment Number, Last four only
Please upload copy of Tribal ID, or HCN Verification

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Last 4 of SSN *
Gender *
Race and Ethnicity
What is your HCN Legislative District
Address *

Address

Street Address Line 2

City State

Zip Code
Phone
Email Address
example@example.com
Current Landlord Name / Property Management Company *
Monthly Rental Amount *
Contact Phone *
Landlord Email
example@example.com
Address of Landlord *
Copy of your current rental agreement or lease

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Are you an enrolled member of the Ho-Chunk Nation

Yes No, If no is checked please answer next question.
If no, are you a Native American enrolled in a federally recognized tribe?

Yes No
please include enrollment information.

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In the last 90 days, has anyone in your household been unemployed 90 days or longer?

Yes No
Household size, (total number of adults and minors that live in rental unit)
Emergency Rental Assistance Program funds will be used for the following activities:

a. Rent (current)--Applicants can apply for rental assistance for current month’s rent. Up to $1,000.00 per month.

b. Prospective Rent (future rent)--Financial assistance for a period up to 12 months, up to 12,000.00 maximum. Must re-certify income eligibility every 3 months.

c. Rental arrears--ERAP assistance can pay for arrears as far back as March 13, 2020. 12,000.00 maximum.

d. Utilities and home energy costs--Current month’s utility statement amount. Up to $300. e. Utilities and home energy costs arrears--ERAP assistance can pay for arrears as far back as March 13, 2020, $3,600 maximum amounts.
Household member 1.
Income Data, (Fill out for each member of household.)
Name blanks* . Date of Birth blank* Last 4 digits of social security number. * Tribal Enrollment Number * .Monthly Income, * , Income Source, *
Household Member 2.
Income Data, (Fill out for each member of household.)
Name blanks . Date of Birth blank Last 4 digits of social security number. Tribal Enrollment Number .Monthly Income, , Income Source,
Household Member 3.
Income Data, (Fill out for each member of household.)
Name blanks . Date of Birth blank Last 4 digits of social security number. Tribal Enrollment Number .Monthly Income, , Income Source,
Household Member 4.
Income Data, (Fill out for each member of household.)
Name blanks . Date of Birth blank Last 4 digits of social security number. Tribal Enrollment Number .Monthly Income, , Income Source,
Household Member 5.
Income Data, (Fill out for each member of household.)
Name blanks . Date of Birth blank Last 4 digits of social security number. Tribal Enrollment Number .Monthly Income, , Income Source,
Household Member 6.
Income Data, (Fill out for each member of household.)
Name: blanks . Date of Birth blank Last 4 digits of social security number. Tribal Enrollment Number .Monthly Income, , Income Source,
Household Member 7.
Income Data, (Fill out for each member of household.)
Name blanks . Date of Birth blank Last 4 digits of social security number. Tribal Enrollment Number .Monthly Income, , Income Source,
Household Member 8.
Income Data, (Fill out for each member of household.)
Name blanks . Date of Birth blank Last 4 digits of social security number. Tribal Enrollment Number .Monthly Income, , Income Source,
Household Member 9.
Income Data, (Fill out for each member of household.)
Name blanks . Date of Birth blank Last 4 digits of social security number. Tribal Enrollment Number .Monthly Income, , Income Source,
Please update all income data for your household. (A completed 2020 1040 Tax Return will be the most convenient method of income verification.)

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This box below should equal total monthly amount of household income.
Do you or any individual in your household qualify for unemployment benefits?

Yes No
Have one or more individuals in your household experienced any of the following financial hardship due, directly or indirectly, to the Covid-19 pandemic? (check all that apply)

A reduction in household income Loss of employment / temporary layoff or furlough Reduction in hours / pay Unable to work or experiencing financial hardship due to no child care / school. Underlying medical condition req Loss of self employment / business income. Over the age of 50 and enduring increased costs because of the covid-19 pandemic. Disabled and enduring increased costs because of the COVID-19 pandemic Incurred significant costs (hospital bills, medication costs, etc) Other financial hardship
Housing Instability Information
Does one or more individuals in your household face a risk of experiencing homelessness or housing instability, which may include (check all that apply);

Currently Homeless Past due utility with disconnect notice or rent notice or eviction notice due to non-payment. Any other evidence of such risk. None
If you checked any of the above, attach the supporting documentation demonstrating each type of housing instability (e.g. past due utility or rent notice, or documentation of any other evidence of risk.) ` If you check any of the boxes above, please describe the details of your housing instability at present time.
Rent Arrears and Utility Costs Arrears:

Only includes Rent Arrears and Utility Costs Arrears incurred on or after March 13, 2020.

Arrears includes: interest charges and penalties accrued from the date on which the first missed payment after March 13, 2020

doesinclude: Arrearsnotinterest charges or penalties accrued for Rent Arrears or Utility Costs Arrears incurred before March
Rent Arrears and Utility Cost Arrears

Do you have any Rent Arrears or Utility Costs Arrears? (check all that apply) If you check any of the boxes below, attach supporting documentation for each arrears payment (rental lease, documents showing rent or utility costs arrears and interest accrued, etc.)
Are you applying for rental arrears, (back rent)

Yes No
Total amount of current rental arrears (back rent or any unpaid rent and fees since March 13th, 2020.)
Please provide rental statement / ledger from your landlord.
Rental Statement / rent ledger from you landlord showing past due rent. Must be legible. Can be a pdf, jpeg, or other image format.

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Utility Arrears
Are you applying for Utility Arrears, If yes please check the utilities you need assistance with and be sure to include copies of your utility statements.

Yes No
Utility Arrears you are applying for

Natural Gas / Propane / Fuel Oil Electricity Water / Sewer Trash Removal
What is the total amount of utility arrears you are applying for.
Natural Gas / Propane/ Fuel Oil Provider
Natural Gas / Propane / Fuel Oil : Total Amount Owed
Account Number
Phone Number
Payment Submission Address

Payment Address

Street Address Line 2

City
State
Zip
Natural Gas / Propane / Fuel Oil Provider Billing Statement / Invoice

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Electricity Utility Provider
Electricity: Amount
Account Number
Phone Number
Address

Payment Address

Street Address Line 2

City
State
Zip
Electricity Provider Statement / Bill

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Water / Sewer Provider / Municipality
Amount
Account Number
Phone Number
Address

Payment Address

Street Address Line 2

City
State
Zip
Water / Sewer Provider Statement / Bill

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Trash Removal Provider
Amount Owed
Account Number
Phone Number
Address

Payment Address

Street Address Line 2

City
State
Zip
Trash Removal Provider Statement / Bill

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Other Housing Expense
Do you expect to be unable to pay any other Housing Expenses? (Expenses related to housing incurred due, directly or indirectly, to the novel coronavirus disease ( If you check any of the boxes below, attach supporting documentation for each housing expenses payment due Payment due:

Yes No
Other Housing Expense blanks Payment is due:
Amount Due
Date Due

Month Day Year
Date
Provider
Phone Number
Address

Payment Address

Street Address Line 2

City
State
Zip
Email
example@example.com
Provide copy of the Statement or Bill of the housing expense you are applying for.

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Certifications and Signature Section
TO THE APPLICANT: By signing this Form, you are certifying that you have not already received funding or benefit from Emergency Rental Assistance from any other source for the same assistance being applied for with this Form ("Duplicative Benefit" If you have received such, Rental Assistance funding or direct benefit, or have a question about whether you have received a duplicative benefit, please note what that is below:
By my signature below, I hereby certify that all of the foregoing information and attached documentation is true and correct. I understand that providing any false statements, false information, any misleading statements or information, or if I fail to notify Ho-Chunk Housing and Community Development Agency of changes to my household's eligibility, will be grounds for denial of the application or, if assistance has already been granted, recapture of any funds granted, and may be grounds civil or criminal prosecution if Ho-Chunk Housing Community Development Agency determines it is appropriate to do so.
APPLICANT SIGNATURE

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DATE

Month Day Year
Date
If a landlord or owner of a residential dwelling submits this Form on behalf of the Applicant:

, the Applicant's landlord/residential dwelling owner, understand that I am

required to provide this application to the Applicant after completing and submitting it.
LANDLORD SIGNATURE

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DATE

Month Day Year
Date
Additional Requirements

Applicants must sign a release of information form allowing the Ho-Chunk Housing and Community Development Agency to verify any and all information required to participate in the COVID-19 Emergency Rental Assistance Program. For each additional month that applicants seek Financial Assistance under the ERA Program, they must submit information and documentation for the rent and utility costs for that month and prospective months for which they
Attestation Applicant Acknowledgements

I understand that I am required to update my application whenever any determining factor of eligibility changes. This includes employment/annual income, contact information, no longer qualifying for unemployment benefits, no longer experiencing a reduction in household income or other financial hardship, no longer facing a risk of homelessness or housing instability, or having a household income that is above 80 percent of the Area Median Income for the household.
Signature of Applicant

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DATE

Month Day Year
Date
AUTHORIZATION FOR THE RELEASE OF INFORMATION
I/we, the undersigned, with this, authorize the HO-CHUNK HOUSING AND COMMUNITY DEVELOPMENT AGENCY and their agents to obtain any information, necessary, to process the Emergency Rental Assistance Program (ERAP) application. This information may be obtained from the following sources, and of the Programs of the HO-CHUNK NATION, Federal, State, and Local governments and any of their agencies and representatives, Law Enforcement Agencies, Financial Institutions and current and prior landlords. This is not all inclusive and may include any additional agency, government, or private source, as deemed necessary by the HO-CHUNK HOUSING AND COMMUNITY DEVELOPMENT AGENCY and/or their agents.

I/we, the undersigned, with this, release the HO-CHUNK HOUSING AND COMMUNITY DEVELOPMENT AGENCY and/or their agents any requested information from the following agencies: Federal, State, And Local governments Law Enforcement Agencies, Financial Institutions, and current or prior landlords.

The information request may be given by fax, telephone, or in writing. This release is valid for fifteen (15) months from the date of the applicant's signature. This release is valid if photocopied and does not have to have an original signature.

I/we have read the terms and conditions of the AUTHORIZATION FOR THE RELEASE OF INFORMATION and with this, give consent for the release of any requested information.
PRINT NAME OF APPLICANT
SIGNATURE OF APPLICANT

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S.S.N. OF APPLICANT
DATE OF BIRTH

Month Day Year
Date
TODAY'S DATE

Month Day Year
Date
PRINT NAME OF CO APPLICANT
SIGNATURE OF CO APPLICANT

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S.S.N. OF CO APPLICANT (last four digits)
DATE OF BIRTH of CO APPLICANT

Month Day Year
Date
TODAY'S DATE

Month Day Year
Date
Check List

Please check of the items listed if you have attached your items to assist you in submitting your application. Applications that are turned in without the supporting documentation can not be processed for payment.
COVID-19 Emergency Rental Assistance Program
Please review your application to make sure that it contains the following information: For all Applicants

Current rental lease
Submit the following documentation if applicable

Income Verification Documentation Documents showing Rent Arrears and interest/penalties accrued or eviction notice Tribal Verification Tribal ID can be expired, Certificate Degree of Indian Blood,
Percapita statement with full name and Tribal ID

Documents showing Utility Costs Arrears and interest/penalties accrued Current Utility bills showing current Utility Costs due (Entire Bill) Documents showing other expenses related to COVID-19 for which payments are due Signed Release of Information Form
All required documents must be attached in order to be considered for assistance.

HO-CHUNK HOUSING AND COMMUNITY DEVELOPMENT AGENCY

P. O. BOX 730, TOMAH, WI 54660
Should be Empty:

COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM

Housing Instability Information

Rent Arrears and Utility Cost Arrears

Utility Arrears

Other Housing Expense

Certifications and Signature Section

Additional Requirements

Attestation Applicant Acknowledgements

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Check List