UPDATED NATIONAL CITY COVID-19 TENANT BASED ......PARTNERSHIPS PROGRAM (HOME) WILL ASSIST LOW INCOME HOUSEHOLDS IN NATIONAL CITY WHO HAVE SUFFERED A LOSS IN INCOME AND ARE UNABLE TO

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PERSONAL DECLARATION AND QUESTIONNAIRE FOR RENTAL ASSISTANCE

DISCLAIMER NOTICE

THIS COVID-19 RENTAL ASSISTANCE PROGRAM IS MADE AVAILABLE THROUGH LIMITED

GRANT FUNDS PROVIDED BY THE CITY OF NATIONAL CITY UNDER THE HOME INVESTMENT

PARTNERSHIPS PROGRAM (HOME) WILL ASSIST LOW INCOME HOUSEHOLDS IN NATIONAL CITY

WHO HAVE SUFFERED A LOSS IN INCOME AND ARE UNABLE TO PAY THEIR PAST DUE RENT

BECAUSE OF FINANCIAL PROBLEMS RELATED TO COVID-19.

SUBMISSION OF THIS APPLICATION AND THE REQUIRED SUPPORTING DOCUMENTATION

IN NO WAY GUARANTEES APPLICANT’S ACCEPTANCE INTO THE PROGRAM OR THE

PROVISION OF ANY OTHER HOUSING ASSISTANCE BENEFITS, EVEN IF ALL ELIGIBILITY

REQUIREMENTS ARE SATISFIED. ALL AWARDS ARE CONTINGENT ON AVAILABLE

FUNDING. GIVEN THE HIGH DEMAND AND LIMITED FUNDING ASSOCIATED WITH THIS

PROGRAM, APPLICANTS SHOULD NOT RELY SOLEY UPON THE SUBMISSION OF THIS

APPLICATION FOR HOUSING ASSISTANCE BENEFITS AND ARE STRONGLY ADVISED TO

SIMULTANEOUSLY PURSUE ANY AND ALL OTHER HOUSING OPPORTUNITIES WHICH

MAY BE AVAILABLE.

APPLICATIONS WILL BE PROCESSED ON A “FIRST-COME, FIRST-SERVED BASIS” BASED ON

SUBMISSION OF THIS FULLY AND PROPERLY COMPLETED APPLICATION AND ALL REQUIRED

SUPPORTING DOCUMENTS.

UPDATED - NATIONAL CITYCOVID-19 TENANT BASED RENTAL ASSISTANCE

APPLICATION ASSISTANCE, PICKUP, AND SUBMITTAL

Family Resource Center (304 W. 18th St., National City) Monday-Friday, 8 am-12 pm and 1pm-5 pm. South Bay Community Services at 430 F. Street Chula Vista, CA 91910 (Monday- Friday 8:30am-5:00pm) Email: [email protected] (Be sure to attach all supporting documents.)

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PERSONAL DECLARATION AND QUESTIONNAIRE FOR NATIONAL CITY COVID-19 TENANT BASED RENTAL ASSISTANCE

ANSWER ALL QUESTIONS COMPLETELY AND ACCURATELY FOR ALL PERSONS RESIDING OR INTENDING TO RESIDE IN THE ASSISTED UNIT

A. HOUSEHOLD COMPOSITION:

INFORMATION ON ADULTS IN YOUR HOUSEHOLD

1. Head of Household – List your name and personal information: Last Name, First Name, MI Gender Soc Sec Number Date of Birth Place of Birth

Male Female

Best Contact Phone Number Driver’s Lic or ID # White Black/African American Hispanic/Latino Non-Hispanic Asian Pacific Islander American Indian/Alaska Native Other ( )

Address City State Zip Code Check all that apply: Single Married Widowed Divorced Separated Disabled Retired Employed Unemployed Student

2. List your spouse or other adult’s name and personal information: Last Name, First Name, MI Gender Soc Sec Number Date of Birth Place of Birth

Male Female

Relationship to Head of Household Driver’s Lic or ID # White Black/African American Hispanic/Latino Non-Hispanic Asian Pacific Islander American Indian/Alaska Native Other

Check all that apply: Single Married Widowed Divorced Separated Disabled Retired Employed Unemployed Student

If necessary, use blank paper to provide the same information above for each additional adult in the household.

INFORMATION ON CHILDREN IN YOUR HOUSEHOLD

1. List each child, under 18 years old, who lives/stays with you: Last Name, First Name, MI Gender Soc Sec Number Date of Birth Place of Birth

Male Female

Relationship to Head of Household Foster Child? White Black/African American Hispanic/Latino Non-Hispanic Asian Pacific Islander American Indian/Alaska Native Other Yes No

2. List each child, under 18 years old, who lives/stays with you: Last Name, First Name, MI Gender Soc Sec Number Date of Birth Place of Birth

Male Female

Relationship to Head of Household Foster Child? White Black/African American Hispanic/Latino Non-Hispanic Asian Pacific Islander American Indian/Alaska Native Other Yes No

3. List each child, under 18 years old, who lives/stays with you: Last Name, First Name, MI Gender Soc Sec Number Date of Birth Place of Birth

Male Female

Relationship to Head of Household Foster Child? White Black/African American Hispanic/Latino Non-Hispanic Asian Pacific Islander American Indian/Alaska Native Other Yes No

If necessary, use blank paper to provide the same information above for each additional child in the household.

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B. REASONABLE ACCOMMODATION:

Do you require a specific accommodation to fully utilize our agency’s services? Yes No If YES, please specify how we may accommodate your disability: ___________________________________________________________________________________________ ___________________________________________________________________________________________

C. EMPLOYMENT HISTORY:

1. Household member who currently works or worked prior to March 13, 2020:

Last Name, First Name Self-Employed? Date of Hire If currently not working, last day of employment Yes No Hours Worked Weekly Hourly Pay Weekly Tips How often paid? Employer’s Name $ $ Employer’s Address (Street, City, State, Zip) Employer’s Phone # Employer’s Fax # ( ) ( )

2. Household member who currently works o worked prior to March 13, 2020:

Last Name, First Name Self-Employed? Date of Hire If currently not working, last day of employment Yes No Hours Worked Weekly Hourly Pay Weekly Tips How often paid? Employer’s Name $ $ Employer’s Address (Street, City, State, Zip) Employer’s Phone # Employer’s Fax # ( ) ( )

If necessary, use blank paper to provide additional information.

D. INFORMATION ON OTHER INCOME: Please provide current proof of any income reported below. Check YES or NO for each

type of income. If YES, complete all required information for income received or expect to receive by or for any household member, including children. If necessary, report any other additional sources on a separate sheet of paper.

Type of Income Do you have this income?

Who Receives Funds Name and Address of Provider Monthly Amount $

Social Security Benefits - SSA and/or SSI

Yes No

CALWORKS Yes No

Food Stamps/ CalFresh Yes No

State Disability Yes No

Worker's Compensation Yes No

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Unemployment Benefits Yes No

Veteran's Benefits Yes No

Military Pay/Allotment Yes No

Pensions or Retirement Yes No

Child Support Yes No

Spousal Support Yes No

Contributions Yes No

Gifts or Loans Yes No

Rental Property Income Yes No

School Financial Aid Yes No

Other Income Yes No

If necessary, report any other additional sources on a separate sheet of paper.

E. ASSET INFORMATION: Must provide current proof of asset (bank statement, etc.) listed below.

Check YES or NO next to Type of Asset. If YES, complete all information for any asset owned or held by or for any household member, including children.

Type of Asset Do you have this asset? Name(s) on Account Balance/Value Account/Policy # Name and Address of Institution

Cash Yes No $

Checking Account

Yes No

$

$

Savings Account

Yes No

$

$

Other Accounts Yes No $

If necessary, report any other additional assets on a separate sheet of paper.

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F. OTHER INFORMATION:ASSISTANCE NEEDSIs your need for assistance due to COVID-19? If yes, please explain below Yes No

COVID-19 Effect ☐ I had a reduction in work hours due to COVID-19 ☐ I lost my job due to COVID-19 (i.e. business closure temporary, business closure permanent)

☐ I had to resign/take a leave of absence or reduce my hours due to lack of childcare/school closures due to COVID-19 ☐ I had to resign/take a leave of absence due to having [or someone in my household having] a serious underlyingmedical condition [such as heart disease, chronic lung disease, diabetes or cancer] and as a result am unable tocontinue to work due to COVID-19

RENT Have you received rental assistance from any agency from January 2020 to the present day? Yes No

If YES, Who? (List Name) Date (last assistance received) City, State/US Territory Amount

-Are you renting from a relative? Yes No

-Are you in good standing (current with rent payments, no eviction proceedings, etc.) with your Landlord prior to March 13,2020?Yes No Comment:

-What is your monthly rent (must match lease agreement or most recent rental statement):$

-Number of individuals residing in unit:

-Number of bedrooms in unit:

-Landlord’s name: ___________ Landlord’s phone number: ________________

-Have you submitted a letter to your landlord explaining your inability to pay rent due to COVID-19? Yes No

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South Bay Community Services’ funder maintains a policy of zero tolerance for drug-related or violent criminal activity. Per the funder, household members may not engage in drug-related or violent criminal activity, nor may household members engage in any criminal activity that threatens the health, safety or right to peaceful enjoyment of other residents and person residing in the immediate vicinity of the premises (see 24CFR 982.553). Per the funder, prior narcotics or drug abuse offenses must be reported even if the applicant/participant has successfully completed a narcotics or drug abuse diversion program. (Penal Code Section 1000). Per the funder, the record pertaining to the arrest resulting in successful completion of a diversion program shall not, without the divertee’s consent, be used in any way that could result in the denial of any benefit. DRUG RELATED CRIMINAL ACTIVITY: "The illegal manufacture, sale, distribution, use or the possession with the intent to manufacture, sell, distribute or use, of a controlled substance (as defined in the Controlled Substance Act, 21 U.S.C. 802(6))." VIOLENT CRIMINAL ACTIVITY: Any illegal criminal activity that has as one of its elements the use, attempted use, or threatened use of physical force against the person or property of another.

Have you or any household member ever been arrested or involved in any drug related criminal activity? Yes No

If YES, Who? (List Name) Date Involved? City/State or Country (where arrested or involved) Type of Drug involved/arrested for Have you or any household member ever been arrested or involved in any violent criminal activity, including threatened use of physical force against a person or property of another? Yes No If YES, Who? (List Name) Date Involved? City/State or Country (where arrested or involved) List Brief Description of Activity Have you or any household member ever been arrested or involved in any alcohol abuse activity? Yes No If YES, Who? (List Name) Date Involved? City/State or Country (where arrested or involved) List Brief Description of Activity Are you, or any current or future household member subject to a lifetime sex offender registration requirement? Yes No If YES, Who? (List Name) City/State of Registration Date of Registration as Sex Offender Have you or any household member ever been arrested or taken to jail or prison for any reason? Yes No

If YES, Who? (List Name) Date Arrested City/State or Country where arrested Brief Reason for the Arrest

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I. REPORTING RESPONSIBILITIES:

WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES. MAKING FALSE STATEMENTS IS A FELONY UNDER CALIFORNIA STATE LAW (PENAL CODE SECTIONS: 115, 118, 487 AND 532) AND MAY RESULT IN CRIMINAL CHARGES INCLUDING PERJURY, GRAND THEFT, FILING FALSE DOCUMENTS WITH A PUBLIC OFFICE OR AGENCY, AND OBTAINING MONEY UNDER FALSE PRETENSES.

I/We understand that false statements and misrepresentations are punishable under both federal and state laws. Additions to the household must be approved in advance unless they are due to birth, adoption, or court-awarded custody. I/We also understand that I/we may be liable for any claims for unpaid rent, damages or vacancy loss paid by South Bay Community Services on my/our behalf, or for the entire housing assistance payment. I declare, under penalty of perjury under the laws of the United States of America and of the State of California, that the information contained in this questionnaire is true, correct, and complete. Signature of Head of Household Date Signature of Spouse/Other Adult Date Signature of Other Adult Date Signature of Other Adult Date Signature of Other Adult Date Signature of Other Adult Date

SOUTH BAY COMMUNITY SERVICES USE ONLY

I certify I have reviewed this Personal Declaration and Questionnaire for Rental Assistance and all verifications and supporting documents provided as required by program guidelines.

______________ Print Name of Specialist Signature of Specialist Date

South Bay Community Services will not deny any resident the equal opportunity to apply for or receive assistance under any program administered on the basis of race, color, sex, religion, creed, national or ethnic origin, age, familial or marital status, disability, income source, or sexual orientation.

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Each household member 18 years or older must read and sign an Authorization Form for Release of Information. A separate form is included in this package for each adult. If you need additional Authorization forms, please contact South Bay Community Services (SBCS).

AUTHORIZATION FOR RELEASE OF INFORMATION

I, ________________________________________________________________ (legal name),

do hereby authorize any agencies, offices, groups organizations or business firms to release to SOUTH BAY COMMUNITY SERVICES (SBCS) and/or the CITY OF NATIONAL CITY (CITY) any information or materials which are deemed necessary to complete and verify my application for participation and/or to maintain my continued assistance under SBCS’ HOME funded Tenant Based Rental Assistance Program provided through a grant from the CITY . The information needed may include verification or inquiries regarding my identity, household members, employment and income, assets, allowances or preferences I have claimed, and residency. These organizations are to include, but are not limited to: the CITY, your Landlord; financial institutions; Employment Security Commission; educational institutions; past or present employers; Social Security Administration; welfare and food stamps agencies; Veteran’s Administration, court clerks; utility companies; Workmen’s Compensation Payers; public and private retirement systems; law enforcement agencies; medical facilities and credit providers. I further acknowledge and agree that this Authorization also expressly allows SBCS to release and share any of the information stated herein with the CITY.

I understand that SBCS and/or the CITY and/or the Department of Housing and Urban Development (HUD) may utilize third parties to verify information and other computer matching programs in order to verify the information supplied on my application or recertification. It is understood and agreed that this authorization or the information obtained with its use may be given to and used by SBCS and/or the CITY and/or HUD in the administration and enforcement of program rules and regulations and that SBCS and/or CITY and/or HUD may in the course of its duties obtain such information from other Federal State or local agencies, including State Employment Security Agencies; Department of Defense; Office of Personnel Management; the Social Security Administration; and State welfare and food stamp agencies. If there is a discrepancy between the information provided by the above sources and the information that I have provided, I understand that SBCS and/or the CITY may take action to terminate my HOME Tenant Based Rental Assistance will require the repayment of benefits I was not eligible to receive.

It is with my understanding and consent that a photocopy or electronic facsimile of this authorization may be used for the purposes stated above. This authorization is valid for two-years from the date of my signature.

____________________________________________________________________________________ Address City State Zip ____________________________________________________________________________________ Social Security Number Date of Birth Telephone Number ____________________________________________________________________________________ Signature Date Signed

INFORMATION ON ADULTS IN YOUR HOUSEHOLDINFORMATION ON CHILDREN IN YOUR HOUSEHOLDSOUTH BAY COMMUNITY SERVICES USE ONLYAUTHORIZATION FOR RELEASE OF INFORMATION

Last Name First Name MIRow1: Soc Sec NumberMale Female: Date of BirthMale Female: Place of BirthMale Female: Drivers Lic or ID: AddressRow1: CityRow1: StateRow1: Zip CodeRow1: Last Name First Name MIRow1_2: Soc Sec NumberMale Female_2: Date of BirthMale Female_2: Place of BirthMale Female_2: Relationship to Head of HouseholdRow1: Drivers Lic or ID Row1: Last Name First Name MIRow1_3: Soc Sec NumberMale Female_3: Date of BirthMale Female_3: Place of BirthMale Female_3: Relationship to Head of HouseholdRow1_2: Last Name First Name MIRow1_4: Soc Sec NumberMale Female_4: Date of BirthMale Female_4: Place of BirthMale Female_4: Relationship to Head of HouseholdRow1_3: Last Name First Name MIRow1_5: Soc Sec NumberMale Female_5: Date of BirthMale Female_5: Place of BirthMale Female_5: Relationship to Head of HouseholdRow1_4: If YES please specify how we may accommodate your disability 1: If YES please specify how we may accommodate your disability 2: Last Name First NameRow1: Date of HireYes No: If currently not working last day of employmentYes No: Hours Worked WeeklyRow1: fill_33: How often paid: Employers Name: Employers Address Street City State ZipRow1: fill_35: fill_36: Last Name First NameRow1_2: Date of HireYes No_2: If currently not working last day of employmentYes No_2: Hours Worked WeeklyRow1_2: fill_39: How often paid_2: Employers Name_2: Employers Address Street City State ZipRow1_2: fill_41: fill_42: Who Receives FundsYes No: Name and Address of ProviderYes No: Monthly Amount Yes No: Who Receives FundsYes No_2: Name and Address of ProviderYes No_2: Monthly Amount Yes No_2: Who Receives FundsYes No_3: Name and Address of ProviderYes No_3: Monthly Amount Yes No_3: Who Receives FundsYes No_4: Name and Address of ProviderYes No_4: Monthly Amount Yes No_4: Who Receives FundsYes No_5: Name and Address of ProviderYes No_5: Monthly Amount Yes No_5: Yes No: Yes No_2: Yes No_3: Yes No_4: Yes No_5: Yes No_6: Yes No_7: Yes No_8: Yes No_9: Yes No_10: Yes No_11: Names on AccountYes No: AccountPolicy: Name and Address of Institution: Names on AccountYes No_2: AccountPolicy_2: Name and Address of Institution_2: Names on AccountYes No_3: AccountPolicy_3: Name and Address of Institution_3: Names on AccountYes No_4: AccountPolicy_4: Name and Address of Institution_4: Names on AccountYes No_5: AccountPolicy_5: Name and Address of Institution_5: Names on AccountYes No_6: AccountPolicy_6: Name and Address of Institution_6: If YES Who List NameRow1: Date last assistance receivedRow1: City StateUS TerritoryRow1: AmountRow1: If YES Who List NameRow2: Date last assistance receivedRow2: City StateUS TerritoryRow2: AmountRow2: If YES Who List NameRow3: Date last assistance receivedRow3: City StateUS TerritoryRow3: AmountRow3: No Comment: What is your monthly rent must match lease agreement or most recent rental statement: Number of individuals residing in unit: Number of bedrooms in unit: If YES Who List NameRow1_2: Date InvolvedRow1: CityState or Country where arrested or involvedRow1: Type of Drug involvedarrested forRow1: If YES Who List NameRow2_2: Date InvolvedRow2: CityState or Country where arrested or involvedRow2: Type of Drug involvedarrested forRow2: If YES Who List NameRow1_3: Date InvolvedRow1_2: CityState or Country where arrested or involvedRow1_2: List Brief Description of ActivityRow1: If YES Who List NameRow2_3: Date InvolvedRow2_2: CityState or Country where arrested or involvedRow2_2: List Brief Description of ActivityRow2: If YES Who List NameRow1_4: Date InvolvedRow1_3: CityState or Country where arrested or involvedRow1_3: List Brief Description of ActivityRow1_2: If YES Who List NameRow2_4: Date InvolvedRow2_3: CityState or Country where arrested or involvedRow2_3: List Brief Description of ActivityRow2_2: If YES Who List NameRow1_5: CityState of RegistrationRow1: Date of Registration as Sex OffenderRow1: If YES Who List NameRow2_5: CityState of RegistrationRow2: Date of Registration as Sex OffenderRow2: If YES Who List NameRow1_6: Date ArrestedRow1: CityState or Country where arrestedRow1: Brief Reason for the ArrestRow1: If YES Who List NameRow2_6: Date ArrestedRow2: CityState or Country where arrestedRow2: Brief Reason for the ArrestRow2: Date: Date_2: Date_3: Date_4: Date_5: Date_6: Print Name of Specialist: Date_7: do hereby authorize any agencies offices groups organizations or business firms to release to SOUTH: Address: City: State: Zip: Social Security Number: Date of Birth: Telephone Number: Date Signed: Check Box1: OffCheck Box2: OffText3: Text4: Check Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: 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