0920-1303 Eviction Protection Declaration 29MAR2021

OMB Control No. 0920-1303

Expiration Date: XX/XX/2021

Eviction Protection Declaration

The Centers for Disease Control and Prevention (CDC) has issued an order that may protect you from being evicted or removed from where you are living. This means that you may be able to stay at the place where you live through JUNE 30, 2021, if you qualify.

How to use this form

1. See if you qualify for eviction protection under the CDC order. If you’d like help from an expert, contact (800) 569-4287 or go to https://www.hudexchange.info/programs/housing-counseling/rental-eviction/ to get contact information for a local HUD-approved housing counselor.

2. Sign the declaration that you qualify, on the next page.

3. Give the signed declaration page to the individual or company you rent from (for example, building management, landlord, etc.). Keep a picture or copy for your records and call your expert back if there’s a problem.

1. Do I qualify?

AND

If you can check at least one box in each column, you qualify.

Column A

• I received a stimulus check (Economic Impact Payment) in 2020 or 2021

• I was not required to report any income to the IRS in 2020

• In 2020 or 2021, I earned (or expect to earn) less than $99,000 as an individual or less than $198,000 as a joint filer

You are likely to have earned under this amount if you receive any of the following benefits:

• Supplemental Nutrition Assistance Program (SNAP)

• Temporary Assistance for Needy Families (TANF)

• Supplemental Security Income (SSI)

• Supplemental Security Disability Income (SSDI)

None of the above  You do not qualify

You checked at least one item in each column? Your income level qualifies.

[Check the first box on the next page]

Column B

I cannot pay my full rent or make a full housing payment because:

• My household income has gone down substantially

• I have been laid off from work

• My work hours or wages have been cut

• I have extraordinary out-of-pocket medical expenses¹

None of the above  You do not qualify

Troubleshooting tools for tenants

Find emergency rental financial assistance
Call (800) 569-4287 to find a listing for local HUD-approved housing counselors

Report problems with debt collection
Submit a complaint to CFPB cfpb.gov/complaint

Report discrimination
Submit a complaint. Call HUD at (800) 669-9777

2. My Declaration that I qualify

By checking the boxes below, I declare that each statement is true.

• My income level qualifies for the reasons explained above.

• I have done my best to make timely partial payments that are as close as possible to the full payment and to get government assistance in making my rent or housing payments.²

• If I were evicted, I have no other available housing options, so I would:

• Probably become homeless, or

• Have to move to a homeless shelter, or

• Have to move in with others who live in close quarters.

• I understand that after I sign:

• Unless I come to an agreement with my landlord, I am still responsible for rent, back rent, and any fees, penalties or interest under my lease.

• I must still follow the conditions of my lease.

• Unless I come to an agreement with my landlord, if I fail to make my required payments, I could be evicted when this temporary halt of evictions ends.

• I can still be evicted for reasons other than not paying rent or not making a housing payment.

You sign here:

X ______________________________ Date: ­­­­­­__________

I sign this declaration³ under penalty of perjury. That means I promise that the statements above are the truth and that I understand that I can be criminally punished for lying.

3. Give this signed page to the individual or company you rent from.

ATTN LANDLORDS: Thank you for your compliance. If you violate the CDC’s eviction Order, you and/or your business may be subject to criminal penalties, including fines and a term of imprisonment.

1 Defined as 7.5% or more of my adjusted gross income for the year

2 Calling a local expert is the best way to figure out all the help that is available to you. Find a listing for a local HUD-approved housing counselor by calling (800) 569-4287.

3 If you have already signed an eviction moratorium declaration, you do not need to submit another one.