City of Atlanta COVID Rent Assistance Application – Atlanta COVID-19 Emergency Assistance

View the income requirements to respond if your household income is below the maximum amount for the number of people living in your household. You will be required to upload proof of income documentation to submit the application for the Atlanta COVID-19 Emergency Rental Assistance Program. Documentation is not required to submit a request for resources to United Way 2-1-1.
Do you meet the income requirement?*
- Yes
- No
Please select your zip code*
What is your zip code?*
Are you receiving any other rental subsidy (e.g. Housing Choice Voucher, Family Unification Voucher, VASH, Mainstream Voucher, Project-based Section 8, Public Housing, HOME Tenant Based Rental Assistance, Continuum of Care, etc.)?
- Yes
- No
Is your rental subsidy provided through Atlanta Housing Authority?
- Yes
- No

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Your zip code or income does not qualify you to apply for assistance through the Atlanta COVID-19 Emergency Rental Assistance Program. Please continue this form to contact a United Way 2-1-1 agent who will assist you in finding other available resources.

You may also visit 2-1-1 online for other ways to contact 2-1-1 and search the database.
Would you like to submit a request for resources to United Way 2-1-1?*
- Yes
- No
Terms of Service*
You must read the entire terms of service in order to continue to the next page of the application.
Rules
You will be required to verify your crisis and demonstrate your recovery plan. If any provided information or documentation is found to be falsified, your application will be automatically disqualified from receiving assistance.

Confidentiality
We respect your right to receive services while upholding the strictest confidentiality. However, certain laws may require us to breach this confidentiality, such as child abuse/neglect and elderly abuse. In addition, we are required to share your information and/or documentation with (i) the City of Atlanta, (ii) community program providers with whom we have contracted for execution of this program, and (iii) the City of Atlanta’s auditors with respect to which determinations will be made regarding program compliance with all applicable laws, rules, regulations, and guidelines, including compliance with federal grant requirements for distribution of CARES Act funds. You acknowledge that we will share your information and documentation for such purposes and release us from any claims and liabilities arising from the sharing and utilization of your information and documentation for such purposes.

Sharing Information
Your information will be entered into a database platform called Client Track/HMIS (Homeless Management and Information System).

Your information will be viewable by other agencies, such as those that you may be referred to for services. If applicable, any previous data in the ClientTrack/HMIS system prior to this consent may be viewed. This may include your history of homelessness and housing (including your current housing status, present and/or prior living situation, as well as where and when you have accessed services.

Information is only collected that is needed to provide services or that we consider relevant to helping us understand the scope and dimensions of homelessness in order to design effective service delivery. The collection and use of all personal information is guided by strict standards of confidentiality as outlined in the GA HMIS, United Way, and the Service Provider’s privacy policy. You may request a copy of the ClientTrack/HMIS Privacy Policy and the Privacy Policy Temporary Emergency Addendum from your assigned Service Provider.

By submitting this application, you are giving consent for United Way and/or your assigned Service Provider to enter your personal information into the GA HMIS System.

Records
Records will be maintained for 7 years.

Refusal of Services
You have the right to refuse services at any time.

Other
You have the right to be treated fairly and honestly by staff and staff expect the same in return.
- I understand the terms of service and give consent to proceed.

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Housing Assistance Request
What type of property do you rent or own?*
Do you have a current lease?*
- Yes
- No
What is your base monthly rent or mortgage payment?*
Are you past due on your rent or mortgage?*
- Yes
- No
How much is your past due rent or mortgage?*
Landlord/Property Manager/Mortgage Company*
Landlord/Property Manager/Mortgage Company Contact Name
First Last
Landlord/Property Manager/Mortgage Company Address*
Address you mail your rent payment to.

Street Address Address Line 2 City State ZIP Code
Landlord/Property Manager/Mortgage Company Phone*
Name on Account*
First Last
Eviction/Payment Deadine*
Gas Utility Assistance
Gas Service Provider*
Gas Service Provider Address*
Street Address Address Line 2 City State ZIP Code
Gas Service Provider Phone Number*
Name on Gas Billing Account*
First Last
Gas Billing Account Number*
Total Amount of Past Due Gas Bills*
What is your estimated gas bill for this month?*
Electric Utility Assistance
Electric Service Provider*
Electric Service Provider Address*
Street Address Address Line 2 City State ZIP Code
Electric Service Provider Phone Number*
Name on Electric Billing Account*
First Last
Electric Billing Account Number*
Total Amount of Past Due Electric Bills*
What is your estimated electric bill this month?*
Security Deposit Assistance
Are you in the process of moving due to an eviction and need help with your security deposit?*
- Yes
- No
How much is your security deposit?*

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Please select the Service Provider you would prefer to work with to process your application.*
Required Documentation
Please save the form and gather all required documents. Your documents will not be available if you save and return after they are uploaded and will need to be uploaded again.
1. Applicant’s Photo ID - a copy of either your license, state-issued ID, or government-issued ID
2. Proof of Income for each adult member of the household excluding dependents who are full-time students (monthly paystubs, SSD/SSI/SS award letter, bank statements, unemployment, retirement, child support, letter from employer showing amount earned in period covered [if cash-based]). The Applicant’s current household income must not exceed 80% AMI as defined by the US Department of Housing and Urban Development for renters; or 100% AMI for homowners.
3. Proof of Residence (current lease or mortgage statement) – applicant’s name must be on the lease or mortgage statement for homeowners
4. Proof of Extenuating Circumstance (e.g. separation/furloughed notice, reduced hours, check stubs showing work hours before and after the onset of the pandemic, verification of sick leave, FMLA, a copy of utility bills showing an increase due to the pandemic, copies of medical bills incurred after the onset of the pandemic, etc.)
5. Current or Past Due Bill (Late or Eviction Notice, Mortgage Statement with Past Due Amounts, Rent Statement, Gas, Electric)
Applicant's Photo ID*
Accepted file types: jpeg, jpg, gif, png, pdf.
Proof of Income*
Provide paystubs, SSD/SSI/SS award letter, bank statements, unemployment, retirement, child support or letter from employer showing amount, if cash-based, showing previous month from the date of application.
Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf.
Proof of Income prior to March 1, 2020*
Provide paystubs, SSD/SSI/SS award letter, bank statements, unemployment, retirement, child support or letter from employer showing amount, if cash-based, showing February 2020.
Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf.
Proof of Residence*
Current lease or mortgage statement, the applicant’s name must be on the lease/mortgage statement.
Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf.
Proof of Extenuating Circumstance*
Separation/furloughed notice, reduced hours, check stubs showing work hours before and after the onset of the pandemic, verification of sick leave, FMLA, a copy of utility bills showing an increase due to the pandemic, copies of medical bills incurred after the onset of the pandemic, etc.
Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf.
Current and/or Past Due Bills*
Late or Eviction Notice, Mortgage Statement with Past Due Amounts, Rent Statement, Gas, Electric
Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf.

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Summary of Income and Expenses
These fields are calculated with your previous entries and cannot be changed below. If they are not correct, please go back and review what you provided in the income and expenses fields and these will update.
Total Household Income
Total Monthly Bills
Total Amount of Past Due Bills
Security Deposit Amount
What is the amount you are able to pay?*
What is the amount of assistance you are requesting?*
Please review your submissions below.

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Program Evaluation Consent
The City of Atlanta is working with the University of Pennsylvania to evaluate the measures and outcomes of the Atlanta COVID-19 Emergency Rental Assistance Program. As an Atlanta COVID-19 Emergency Rental Assistance Program applicant, you are being asked to:

Give consent/authorization to the City of Atlanta and its respective agents, employees, and assigns, to share, disclose, analyze, and discuss all documentation and information provided within this application and in subsequent communications related to Atlanta’s COVID-19 Emergency Rental Assistance Program.

Agree to participate in the evaluation of this program, which will help improve the City’s service delivery and potentially expand resources for rent support and affordable housing. This may involve filling out follow up surveys.

(Note: Your willingness to be involved in this program evaluation will not affect your eligibility or selection for this program in any way.)
Please select whether or not you consent to participate in the evaluation*
- I consent to participate in the evaluation
- I do not wish to participate in the evaluation
Comments
This field is for validation purposes and should be left unchanged.

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Atlanta COVID-19 Emergency Housing Assistance Program

Personal Information

Applicant Household Information

Applicant Demographics

Housing Assistance Request

Gas Utility Assistance

Electric Utility Assistance

Security Deposit Assistance

Required Documentation

Summary of Income and Expenses

Program Evaluation Consent

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