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CARES Emergency Rental Assistance

Personal Declaration and Questionnaire for CARES Emergency Rental Assistance

Answer all questions completely and accurately for all persons residing in the assisted unit

    A: HOUSEHOLD COMPOSITION

    INFORMATION ON ADULTS IN YOUR HOUSEHOLD-MUST MATCH LEASE AGREEMENT OR PROVIDE LETTER OF EXPLANATION

    Your Name

    Your Email Address

    Your Gender

    MaleFemale

    Your Social Security Number (Format: 123-45-6789)

    Your Date of Birth (Format: DD-MM-YYYY [example: 01-01-1975])

    Your Place of Birth

    Your Contact Phone Number

    Your Driver's Lic or ID#

    Your Race/Ethnicity

    WhiteBlack/African AmericanHispanic/LatinoNon-HispanicAsianAmerican Indian/Alaska NativeOther

    Spouse/Other Adult's Name

    Spouse/Other Adult's Email Address

    Spouse/Other Adult's Gender

    MaleFemale

    Spouse/Other Adult's Social Security Number

    Spouse/Other Adult's Date of Birth

    Spouse/Other Adult's Place of Birth

    Spouse/Other Adult's Contact Phone Number

    Spouse/Other Adult's Driver's Lic or ID#

    Spouse/Other Adult's Race/Ethnicity

    WhiteBlack/African AmericanHispanic/LatinoNon-HispanicAsianAmerican Indian/Alaska NativeOther

    Your Full Address (Street, City, State, ZIP)

    Your Residence Type

    ApartmentCondoTownhomeSingle Family HomeMobilehome

    Please check all that apply: 

    SingleMarriedWidowedDivorcedSeparatedDisabledRetiredEmployedUnemployedStudent

    INFORMATION ON CHILDREN IN YOUR HOUSEHOLD

    Do you have children living in the house? If so please enter their details. If not, please scroll down.
    Child #1

    Child #1 Name:
    Child #1 Sex: MaleFemale
    Child #1 Date of Birth:
    Child #1 Place of Birth:
    Child #1 Social Security Number:
    Child #1 Relationship to Head of Household:
    Child #1 Foster Child?: YesNo
    Child #1 Race: WhiteBlack/African AmericanHispanic/LatinoNon-HispanicAsianAmerican Indian/Alaska NativeOther

    Child #2

    Child #2 Name:
    Child #2 Sex: MaleFemale
    Child #2 Date of Birth:
    Child #2 Place of Birth:
    Child #2 Social Security Number:
    Child #2 Relationship to Head of Household:
    Child #2 Foster Child?: YesNo
    Child #2 Race: WhiteBlack/African AmericanHispanic/LatinoNon-HispanicAsianAmerican Indian/Alaska NativeOther

    Child #3

    Child #3 Name:
    Child #3 Sex: MaleFemale
    Child #3 Date of Birth:
    Child #3 Place of Birth:
    Child #3 Social Security Number:
    Child #3 Relationship to Head of Household:
    Child #3 Foster Child?: YesNo
    Child #3 Race: WhiteBlack/African AmericanHispanic/LatinoNon-HispanicAsianAmerican Indian/Alaska NativeOther

    B: INFORMATION ON INCOME

    Please complete the following for household income. Check either YES or NO for each type of income. If YES, complete all required information for income and provide award letters, income statements, etc. that are received by or for any household member, including children within the last 30-days.

    In the past 30 days, have you or anyone in your household received income from earned income/employment? YesNo
    In the past 30 days, have you or anyone in your household received income from social security benefits - SSA and/or SSI? YesNo
    In the past 30 days, have you or anyone in your household received income from CALWORKS? YesNo
    In the past 30 days, have you or anyone in your household received income from Food Stamps/CalFresh? YesNo
    In the past 30 days, have you or anyone in your household received income from state disability? YesNo
    In the past 30 days, have you or anyone in your household received income from worker's compensation? YesNo
    In the past 30 days, have you or anyone in your household received income from unemployment benefits? YesNo
    In the past 30 days, have you or anyone in your household received income from veteran's benefits? YesNo
    In the past 30 days, have you or anyone in your household received income from military pay/allotment? YesNo
    In the past 30 days, have you or anyone in your household received income from pensions/retirement? YesNo
    In the past 30 days, have you or anyone in your household received income from child support? YesNo
    In the past 30 days, have you or anyone in your household received income from spousal support? YesNo
    In the past 30 days, have you or anyone in your household received income from contributions? YesNo
    In the past 30 days, have you or anyone in your household received income from gifts or loans? YesNo
    In the past 30 days, have you or anyone in your household received income from rental property income? YesNo
    In the past 30 days, have you or anyone in your household received income from school financial aid? YesNo
    In the past 30 days, have you or anyone in your household received income from other income? YesNo

    If you answered "Yes" to any of the above, please provide the following information for EACH type of income: 1) who receives the funds, 2) name & address of the provider/employer, 3) monthly amount ($).

    C: ASSET INFORMATION

    Please answer the following questions regarding your assets.

    Do you or anyone in your household have cash (liquid asset)? YesNo
    Do you or anyone in your household have a checking account (liquid asset)? YesNo
    Do you or anyone in your household have savings? YesNo

    If you answered "Yes" to any of the above, please provide the following information for EACH type of asset: 1) has the asset/name on the account, 2) balance/value, 3) interest earned ($), 4) account #/policy # 5) name and address of institution:

    D: OTHER INFORMATION

    Please check ALL that apply:

    Rent:
    Are you renting from a relative? YesNo
    Do you have a co-signer? YesNo
    Have you received rental assistance from the City of Chula Vista or any Agency in the past 6 months? YesNo
    Are you facing eviction proceedings for issues other than non-payment of rent from March 1 to the present? YesNo
    Have you received any of the following from March 1, 2020 to the present?3-Day or 10-Day Notice30-60-90 Day NoticeNuisance NoticeNone of these
    If you received a notice above, please provide details:
    What is your monthly rent?
    Number of individuals residing in your unit?
    Number of bedrooms in your unit?
    Was your monthly income sufficient to pay your rent on January 1, 2020? YesNo
    How much back-rent do you owe? (if none please put $0)
    March 2020:
    April 2020:
    May 2020:
    June 2020:
    July 2020:
    August 2020:
    September 2020:

    Please send us a copy/photo of the following documents for you and all other adults in household:
    1) ID/Driver's Lic.
    2) Lease
    3) Unemployment compensation letter or other evidence of income loss/economic hardship
    4) Tax return
    5) Most recent bank statement (last 30 days)
    Supported file formats include .doc, .docx, .pdf, .png, .zip and .jpeg.

    If you have trouble uploading your documents, you can still submit this form, but your application may be delayed while we wait for you to mail these documents.

    E: 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.
    will be processed first with priority given to those who are unemployed and receiving Unemployment Benefits. Incomplete information and/or unverifiable information may result in
    denial of assistance.
    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.
    Please type your full name here, representing an electronic signature and your agreement to the above statements:
    Please have your all other adults in household type their full names here, representing an electronic signature and their agreement to the above statements:
    Other Adult 1:
    Other Adult 2:
    Other Adult 3: