Application for Emergency Rental Assistance

Who’s applying? Tenant Landlord (on behalf of tenant)

Tenant Information
Last Name First Name SSN#
Gummo Curtis 189723197
Address City Zip County
221 ash circle Centrehall 16828 Centre
Phone Email Address Date
814-883-9422 Curtisgummo@yahoo.com 5/19/22

Household: 1
Number of Adults ____________ 1 five year old
Number of Children under 18 ____________

Has anyone in your household experienced financial hardship which may include, but not limited to, a period of
unemployment, a decrease in household income or had increased household costs? Yes No

If Yes, was this financial hardship due, directly or indirectly, to COVID–19? Yes No

Is anyone in your household at risk of homelessness or housing instability? Yes No

Has anyone in the household received federally funded rental assistance in the past 12 months? Yes No

Are you a veteran? Yes No Has anyone been a victim of domestic violence? Yes No

Citizenship: US Citizen Permanent Resident Temporary Resident Refugee Other

Race (check all that apply): American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Pacific Islander White Other

Ethnicity: Hispanic Non-Hispanic Gender: Male Female

Landlord or Property Manager Information

Property Management Company (if applicable)

Last Name First Name Tax ID# or SSN#

Moyer Gary
Address City Zip
Centrehall 16828
Phone Email Address
814-364-2130

Tenant Utility Information

Company Name Address (Street, City, Zip) Phone Account #
Westpenn power 100149349

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 Tenant Household Income
Please tell us about the income of any individual in your household who is 18 or over.
Does anyone in your household have any income? Yes No
If yes, check all that apply, and list the income you have already received.

Commissions Money Paid to You for Rent Support

Dividends Money Paid to You for Room or Board Unemployment
Gambling/Lottery Pensions Union Pay
Guardian Fees Self-Employment Veteran Benefit
Money Earned from Babysitting Sick Benefits Wages from Employment
Money for Training Social Security Workers Compensation
Money Paid to You for Loans Supplemental Security Income (SSI) Work
Other:________________

Income/Pay: How Often Date of Most

Name of Person with Income Type/Source of Income/Name of Employer
How Much? Paid Recent Payment
Curtis gummo Walmart 17.50 2 weeks 5/12/22

Tenant Household Expenses

Rent 370.00
Monthly $_______________________ Arrears $_______________________
Electric 4450.44
Monthly $_______________________ Arrears $_______________________
Gas ?
Monthly $_______________________ Arrears $_______________________
Oil Monthly $_______________________ Arrears $_______________________
Propane Monthly $_______________________ Arrears $_______________________
Coal/Wood/Other 1000.00 yearly
Monthly $_______________________ Arrears $_______________________
Trash 26.00
Monthly $_______________________ Arrears $_______________________
Water/Sewer Monthly $_______________________ Arrears $_______________________
Notes:

ERAP Agency Use Only

Authorization Information: Approved Denied Date:________________________
Type(s) of Assistance Provided:
Rental Assistance Rental Arrears Housing Stability Services Utility Assistance Utility Arrears
Amount of Assistance:
Rental Assistance $_______________ Rental Arrears $_______________ Housing Stability $_______________
Utility Assistance $_______________ Utility Arrears $_______________ Total $____________________
Number of months covered with: Rental Assistance____________ Utility Assistance____________
Household Income Level:
Does not exceed 30 percent of the area median income for the household
Exceeds 30 percent but does not exceed 50 percent of the area median income for the household
Exceeds 50 percent but does not exceed 80 percent of area median income for the household
Notes: Used 2020 annual calculation for eligibility Used monthly income at time of application

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 Rights and Responsibilities
RIGHT TO NONDISCRIMINATION PRIVACY ACT STATEMENT
This institution is prohibited from discriminating on the The collection of this information, including the Social
basis of race, color, national origin, disability, age, sex Security number (SSN) of each household member, is
and in some cases religion or political beliefs. authorized under 42 U.S.C. § 405(c)(2)(C)(i-iv) and 62
Persons with disabilities who require alternative means P.S. § 432.2(b)(3).
of communication for program information (e.g. Braille, The information will be used to determine whether
large print, audiotape, American Sign Language, etc.), your household is eligible or continues to be eligible
should contact the Agency (State or local) where they to participate in the Emergency Rental Assistance
applied for benefits. Additionally, program information Program. We will verify this information through
may be made available in languages other than English. computer matching programs. This information will
To file a complaint of discrimination regarding a program also be used to monitor compliance with program
receiving federal financial assistance through the U.S. regulations and for program management.
Department of Health and Human Services (HHS): This information may be disclosed to other federal
(1) mail: U.S. Department of Health and Human Services (HHS) and state agencies for official examination, and to law
HHS Director, Office for Civil Rights, Room 515-F enforcement officials for the purpose of apprehending
200 Independence Avenue, S.W. persons fleeing to avoid the law. Failure to provide
Washington, D.C. 20201; or an SSN may result in the denial of Emergency Rental
(2) call: (202) 619-0403 (voice) or (800) 537-7697 (TTY). Assistance to each individual failing to provide an SSN.
Any SSNs provided will be used and disclosed in the
This institution is an equal opportunity provider. same manner as SSNs of eligible household members.
If someone wants help getting an SSN:
RIGHT TO CONFIDENTIALITY
We will keep your information private. It will only be (1) call: 1-800-772-1213 or 1-800-325-0778 (TTY); or
used to decide which programs you may be eligible (2) visit: www.ssa.gov.
for. Any person knowingly violating any of the rules
and regulations of this department shall be guilty of a RIGHT TO APPEAL
misdemeanor and, upon conviction shall be sentenced to You have the right to ask for a DHS hearing to appeal
pay a fine, not exceeding one hundred ($100) dollars, or a decision if you believe it is unfair or incorrect, or if the
to undergo imprisonment, not exceeding six months, or provider fails to act on your application for benefits. You
both (62 P.S. section 483). may file the appeal at:

RESPONSIBILITY TO PROVIDE INFORMATION DHS Office of Hearings and Appeals

You must give true, correct and complete information. PO Box 2675
You must help in proving the information, you give. Harrisburg, PA 17105.
Benefits may be denied if you fail to provide certain proof. If you appeal, you may also request a conference
If you are contacted by Department of Human Services before the hearing by contacting the Emergency Rental
(DHS) or the Office of State Inspector General, you must Assistance Program (ERAP) program manager via
fully cooperate with those persons or investigators. email at: RA-PWERAPOIM@pa.gov.

At the hearing you may represent yourself, or someone

else, such as a lawyer, friend or relative may represent
you.

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 Attestation/Certification

I understand and agree that I am responsible for any fraudulent statements made on this application, even if the
application is being submitted by someone acting on my behalf. I certify that all information that has been entered is
true under penalty of perjury. I understand that the information entered in this application will be kept confidential and
used only to administer benefits. I understand that I may be required to work with other agencies as a condition of my
approval for assistance. I agree to provide upon request any additional documentation required (i.e. pay stub, lease,
recent bills, proof of unemployment etc) to aid in determining eligibility.
Verified by PDFFiller
Signature - Tenant

05-19-2022 00:00
Name Printed - Tenant

Curtis gummo
Signature - Landlord (only if form was completed by landlord)

Name Printed - Landlord (only if form was completed by landlord)

Authorization for Release of Information (Tenant only)

I hereby authorize and request the disclosure to the county office any information concerning the age, residence,
citizenship, employment, income, and any additional information involving eligibility for the rental and utility assistance
programs for myself. It is understood that the information obtained will only be used for determination of rental/utility
assistance or other housing assistance programs.

Signature of Tenant Date

Name Printed - Tenant

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