Rental Assistance Program Summary

The City of Jamestown with funding provided by the U.S. Department of Housing and Urban Development (HUD) is offering rental assistance to households that have been impacted by the Coronavirus (COVID-19)
pandemic. The Rental Assistance Program will be open to individuals whose household income has been reduced as a result of COVID-19, whose projected 2020 annual gross household income does not exceed
eighty (80) percent of the current local median income, and whose household is not receiving rental assistance through other agencies.

Income Guidelines: 2020 for the City of Jamestown
For the purposes of this Rental Assistance Program Grant, use your projected income for 2020.
*Low-to moderate income levels (80 percent of the current local median income)

HOUSEHOLD SIZE:      MAXIMUM HOUSEHOLD INCOME:
1 person                         $37,650.00
2 persons                       $43,000.00
3 persons                       $48,400.00
4 persons                       $53,750.00
5 persons                       $58,050.00
6 persons                       $62,350.00

This program will also benefit the landlords whose rental income has been impacted by the COVID-19 pandemic. Therefore, it is imperative that both the tenant and landlord work together to submit this application, though the ultimate responsibility for submitting the application will be the tenant.
Both the landlord and the tenant must sign a City of Jamestown Property Maintenance Agreement before grant is disbursed. This agreement stipulates that both parties agree to and will cooperate with a Housing
Quality Standard inspection of the interior and exterior of the unit for which rental assistance is given. This inspection will happen at a later date when it is safe to do so. It will be further agreed upon that the property on which the unit sits will remain free of junk and debris, tall grass and overgrown landscaping, unregistered vehicles, and remain compliant with City of Jamestown codes. The tenant agrees to uphold the terms and conditions of their rental agreement. Tenants and landlords are encouraged to set a
repayment agreement for rent that is not covered by this three-month Rental Assistance Program.

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* 1. NAMES and AGES of all members of the household:

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* 2. ADDRESS of RENTAL PROPERTY:

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* 3. Tenant’s Phone Number:

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* 4. Email Address:

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* 5. LANDLORD NAME:

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* 6. LANDLORD ADDRESS:

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* 7. Landlord Phone Number:

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* 8. Landlord Email Address:

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* 9. MONTHLY RENT:

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* 10. INCLUDES UTILITIES:

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* 11. LAST DATE RENT WAS PAID:

Date

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* 12. LAST DATE BPU BILL WAS PAID:

Date

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* 13. HOUSEHOLD INCOME ON MARCH 1, 2020:
(Household income includes income from all persons 18 years of age and older who occupy the home. Proof of household income at March 1, 2020 and current household income is required at time of application.)

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* 14. CURRENT HOUSEHOLD INCOME:

It is of the highest importance to the U.S. Department of Housing and Urban Development (HUD), who is
funding this grant, that there be no duplication of financial assistance. Therefore, all applications will
undergo a rigorous review to ensure that applicants are not receiving other means of financial assistance
for rent.

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* 15. DOES ANY AGENCY SUCH AS, Social Security, Social Security Disability Insurance, Section 8 Housing Choice,
STEL, Evergreen Health Services, Veterans Affairs, Housing Options Made Easy (HOME), or others PROVIDE
RENTAL ASSISTANCE FOR ANY OCCUPANT OF THE HOUSEHOLD?

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* 16. TENANT 1: LAST PLACE of EMPLOYMENT

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* 17. TENANT 1: LAST DATE of EMPLOYMENT

Date

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* 18. TENANT 2: LAST PLACE of EMPLOYMENT

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* 19. TENANT 2: LAST DATE of EMPLOYMENT

Date
LANDLORD INFORMATION: Answer YES or NO to the following questions.

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* 20. DID THE LANDLORD REGISTER YOUR UNIT/PROPERTY WITH THE CITY OF JAMESTOWN

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* 21. IS THE LANDLORD CURRENT, THROUGH FEBRUARY 2020, ON TAXES?

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* 22. IS THE LANDLORD CURRENT, THROUGH FEBRUARY 2020, ON BPU?

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* 23. IS THERE A MORTGAGE ON THE PROPERTY?

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* 24. DOES THIS PROPERTY HAVE A HISTORY OF CODE VIOLATIONS?

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* 25. IS THE PROPERTY FREE OF JUNK AND DEBRIS, UNREGISTERED VEHICLES, AND TALL GRASS AND OVERGROWN LANDSCAPING?

Required Documents
The tenant or landlord must provide the following documentation and submit it with application. You may upload files as PDF, DOC, DOCX, PNG, JPG, JPEG, or GIF.

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* 26. PROOF OF RESIDENCE: (Tenant - utility bill, cable bill, bank statement, etc.)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 27. PROOF OF OWNERSHIP: (Landlord - Deed, mortgage statement, insurance policy, etc.)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 28. CURRENT BPU BILL

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 29. PROOF OF INCOME FOR ALL OCCUPANTS 18 YEARS OF AGE OR OLDER (Most recent pay stubs for three consecutive months)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 30. LEASE AGREEMENT SIGNED BY LANDLORD AND TENANT

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 31. MORTGAGE STATEMENT ON RENTAL PROPERTY, if applicable (Landlord)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 32. PROOF OF TAXES PAID (Landlord)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 33. PROOF OF FINANCIAL HARDSHIP (Tenant - job loss, furlough, or layoff, reduction in hours of work or pay)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File
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