COVID-19 CARES ACT FUNDING

RENTAL AND UTILITY ASSISTANCE

Am I Eligible to Apply for this Assistance?

Do you reside within the city limits of Beaumont? Yes or No; if Yes proceed to next question ˃

Were you employed before March 1st? Yes or No; if Yes proceed to next question ˃

Were you fired, furloughed or laid off due to the COVID pandemic? Yes or No; if your answer is Yes
proceed to the next question ˃

Are you seeking help with Rent/Utilities or both? Circle your choice then proceed to the next question ˃

Is your rent currently subsidized with Federal funds? (Housing Choice Voucher (Section 8), Family
Unification Voucher, Veteran Affairs Supportive Housing (VASH), mainstream Voucher, Project-based
Section 8, Project-based Rental Assistance, or Public Housing Vouchers, etc.)

If you answered Yes to the question above regarding subsidized housing, then you are not eligible to
apply for assistance.

If you answered No to this question, proceed forward ˃

Does your household income exceed eighty-percent (80%) of the 2020 Area Median Family Income
limits for the Beaumont area? Review the income chart below…. If your income is listed in one of these
categories according to the number of household members, you are eligible to apply.

2020 HUD Income Limits

30% of $14,200 $16,200 $18,250 $20,250 $21,900 $23,500 $25,150 $26,750

Median
50% of $23,650 $27,000 $30,400 $33,750 $36,450 $39,150 $41,850 $44,550
Median
60% of $28,380 $32,400 $36,480 $40,500 $43,740 $46,980 $50,220 $53,460
Median
80% of $37,800 $43,200 $48,600 $54,000 $58,350 $62,650 $67,000 $71,300
Median
Effective 7/1/2020; Income limits are published annually by the U. S. Department of Housing and Urban
Development

Application for assistance does not guarantee that you will receive assistance.

INFORMATION TO KNOW BEFORE APPLYING:

Federal funding cannot be used to pay for any property that is located in the floodway. This will be
verified by our office staff, at the start of this process.

If funding is approved, you can receive up to three (3) months of assistance. The maximum amount that
will be awarded to an applicant for their bills will be $3,000.00.

Your rent and utilities cannot be delinquent prior to March 1st. Payment for the months of April,
May and June of 2020 will be paid if needed. If you receive assistance, please note that you will be
ineligible for further assistance unless future funding is made available by HUD.
All requested documentation must be provided at the time of application (list of documents needed
attached). An incomplete application and missing documents will be returned to the applicant.

Once you have all of the necessary documents and a completed application, call Some Other
Place/Henry’s Place at (409)832-7976 or Habitat for Humanity at (409)832-5853 to make an appointment
for an in person interview.

Some Other Place/Henry’s Place or Habitat for Humanity will be sending a form to request rental
verification information to your landlord for the rent that is owed. This form must be signed and returned
by the landlord to the agency that is requesting the information. The monthly amount of rent listed on
your signed and dated lease agreement must match the form completed by your landlord. The only
difference should be if late fees were assessed, and they should be clearly stated on the form.

Upon receipt of the landlord verification, your approved application and the completed environmental
review, payments will be processed.

All rent payments will be made to the landlord and the utility payments will be made to the utility
companies. The applicant will not receive any direct funds according to the HUD guidelines for this
program.

This form must be attached to your application for verification purposes.

Please sign and date this form if you agree with all that has been stated. Failure to submit true and
accurate information will force us to deny your application.

_______________________________________________ ___________________________

Name of Applicant Date

Community Development & Housing Services Department
COVID-19 REQUIRED DOCUMENTS FOR ASSISTANCE

Required Documents to be Included with the Application for Assistance

1. Identification for all Adults in the Household

Acceptable Identification for Adults in the Household:
• State Issued ID Card; OR
• Social Security Card; OR
• Tax Return with all household members listed

2. Proof of Hardship
Acceptable Proof of Hardship Documents:
• Unemployment Letter; OR
• Furloughed Letter; OR
• Check stubs noting decrease of hours or pay; OR
• Personal statement of hardship

3. Proof of Income
Acceptable Proof of Income Documents:
• Check stubs; OR
• SNAP Benefit letter; OR
• Pay history from employer
• Self-Declaration form for all adult household members if you report no income

4. Proof of Household Size

Acceptable Proof of Household Size Documents:
• Tax Return with all household members listed; OR
• SSI Award Letter; OR
• SNAP Benefits Statement; OR
• Medicaid Statement; OR
• Birth certificates for all members of the home: OR
• Social Security cards for all members of the home

5. Proof of Residence
• Signed/dated copy of current lease agreement

6. Other documents needed

Copy of current lease agreement (signed and dated by landlord and tenant)
Copy of utility bills

*** If you have any of the following documents, please include them with your application
• Notice to Vacate
• Court Eviction
 APPLICATION FOR EMERGENCY RENTAL
AND/OR UTILITY ASSISTANCE

REQUESTED ASSISTANCE: Rent _____ Utility ______ Both ______

(1) APPLICANT NAME: _______________________________________________________

(2) CO-APPLICANT NAME: ____________________________________________________

DATE OF BIRTH (1): ________________________ DATE OF BIRTH (2): ______________

ADDRESS: ___________________________________________________________________

PHONE NUMBER (1): __________________________ EMAIL: ______________________

PHONE NUMBER (2): __________________________ EMAIL: ______________________

LIST ALL ADDITIONAL HOUSEHOLD MEMBERS BELOW:

Hispanic SOURCE
NAME DOB RELATIONSHIP RACE Latino INCOME OF
Y or N Y or N INCOME

Race chose the most appropriate

(American Indian or Alaskan Native; Asian; Native Hawaiian or Other Pacific Islander; Black or African American; White)
EMPLOYMENT:
APPLICANT’S EMPLOYER (CURRENT)

NAME: ___________________________________ PHONE NUMBER: ____________

STREET ADDRESS: ___________________________________________________________

YEARS EMPLOYED: _______________________ POSITION: ___________________

SUPERVISOR’S NAME: ________________________________________________________

Please indicate which of the following statement apply to the Applicant:

___ I have experienced a reduction in salary as a result of the COVID19 virus

Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have had a reduction in work hours as a result of the COVID19 virus
Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have been furloughed as a result of the COVID19 virus

Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have been laid off as a result of the COVID19 virus

Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have had a reduction in work hours as a result of the COVID19 virus
Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have been terminated from my job as a result of the COVID19 virus
Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________
EMPLOYMENT:
CO-APPLICANT’S EMPLOYER (CURRENT)

NAME: ___________________________________ PHONE NUMBER: ____________

STREET ADDRESS: ___________________________________________________________

YEARS EMPLOYED: _______________________ POSITION: ___________________

SUPERVISOR’S NAME: ________________________________________________________

Please indicate which of the following statement apply to the Applicant:

___ I have experienced a reduction in salary as a result of the COVID19 virus

Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have had a reduction in work hours as a result of the COVID19 virus
Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have been furloughed as a result of the COVID19 virus

Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have been laid off as a result of the COVID19 virus

Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have had a reduction in work hours as a result of the COVID19 virus
Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____ I have been terminated from my job as a result of the COVID19 virus
Explain: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________
HOUSEHOLD INCOME:
Please indicate an amount and if you are paid weekly (2), bi-weekly (BW), bi-monthly (BM),
monthly (M), or annually (A).

SOURCE $ AMOUNT APPLICANT CO- OTHER

APPLICANT MEMBERS AGE
18+
Gross Salary (before
deductions)
Overtime, Tips,
Bonuses, etc.
Disability

Pensions, Veterans
Benefits, etc
Unemployment/Workers
Compensation
Alimony, Child Support

Welfare Payments
(TANF, Aid to Families
with Dependent
Children, etc)
Other

TOTALS

Are you or the co-applicant on a waiting list for assistance from another agency? __ Yes __ No

If you have answered yes, please list the agency and describe the requested assistance:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Warning: Failure to provide all required documentation will delay assistance and may
result in in the denial of assistance

The information provided in this application is true and complete to the best of my/our
knowledge and belief. I/We consent to the disclosure of such information for purpose of income
verification related to my/our application for financial assistance. I/We understand that any
willful misstatement of material fact will be grounds for disqualification. I/We understand that
the information provided is needed to determine eligibility and in no way assures qualification
for assistance. I/We also agree to provide any other documentation necessary to verify my/our
eligibility.

I/We are aware that all non-exempt information is subject to Texas’s Public Records Law.

________________________________________ ________________________________
Signature of Applicant/Date Signature of Co-Applicant/Date
CERTIFICATION PAGE
It is our policy to verify all information contained in this application. In acknowledgement of this policy,
please sign your name(s) where indicated.

I/We certify the following:

All the information contained and submitted in support of this application is true and complete to the best
of my/our knowledge and belief.

I/We are aware that any misrepresentation will result in the forfeiture of my/our right to participate in the
City of Beaumont’s Tenant Based Rental Assistance Program and may result in legal action against
me/us.

Consent to Release Information: I/We authorize representatives from any of the City of
Beaumont’s Tenant Based Rental Assistance Program that I/We have applied to, my/our employer(s),
my/our financial institution(s), to verify the information contained in this application. This information
includes, but is not limited to employment status, income, and other financial information. I also
authorize representatives from any of the City of Beaumont’s Tenant Based Rental Assistance Program to
allow inspection and reproduction of any financial records or information in their possession. I/We
understand that information in this application may be shared with any of our funding sources for the
purpose of meeting funding compliance.

I/We release all representatives from any of the City of Beaumont’s Tenant Based Rental Assistance
Program from any and all liability arising from release of such information. This authorization is limited
solely to information requested for the processing of my application for the TBRA program.

I understand that completion of this application does not guarantee that my/our eligibility for the program
will be granted for assistance.

________________________________________ ________________________________
Signature of Applicant/Date Signature of Co-Applicant/Date
 Community Planning and Development
Community Development Block Grant (CDBG-CV)

SELF CERTIFICATION OF ANNUAL INCOME BY BENEFICIARY

INSTRUCTIONS: This is a written statement from the beneficiary documenting the definition used to determine “Annual (Gross)
Income”, the number of beneficiary members in the family or household (as applicable based on the activity), and the relevant
characteristics of each member for the purposes of income determination. To complete this statement, select the definition of
income used, fill in the blank fields below, and check only the boxes that apply to each member. Adult beneficiary members must
then sign this statement to certify that the information is complete and accurate, and that source documentation will be provided
upon request.
Definition of Income

o HUD 24 CFR Part 5 o IRS Form 1040 o American Community Survey

Beneficiary Information

Last Name: Beneficiary ID (if applicable):

Member Information

First Names: Member IDs (if applicable): HH CH DIS 62+ S≥18 <18 <15
1
2
3
4
5
6

HH = Head of Household; CH = Co-Head of Household; DIS = Person with disabilities; 62+ = Person 62 years of age or older;
S≥18 = Fulltime student age 18 or over; <18 = Child under the age of 18 years; <15 = Minor under the age of 15 years
Contact Information

Address Line 1: City:

Address Line 2: State: Zip Code:
Income Information

Annual gross income (total of all members) = $

Certification

I/we certify that this information is complete and accurate. I/we agree to provide, upon request,
documentation on all income sources to the HUD Grantee/Program Administrator.

COMPLETE SIGNATURES ON SECOND PAGE

 Community Planning and Development
Community Development Block Grant (CDBG-CV)

SELF CERTIFICATION OF ANNUAL INCOME BY BENEFICIARY

Printed on: Effective Date:
Beneficiary ID:

HEAD OF HOUSEHOLD
Signature Printed Name Date

OTHER BENEFICIARY ADULTS*

Signature Printed Name Date

Signature Printed Name Date

Signature Printed Name Date

Signature Printed Name Date

Signature Printed Name Date

Signature Printed Name Date

Signature Printed Name Date

Signature Printed Name Date

Signature Printed Name Date

Signature Printed Name Date

* Attach another copy of this page if additional signature lines are required.

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section
1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and
willingly making a false or fraudulent statement to a department of the United States Government.
 RENTAL VERFICATION FORM
Landlord Release of Information

Name of Applicant: ______________________________________________

Rental Address: ______________________________________________

I, the above named applicant, hereby give _____________________________(Some Other Place/Henry’s Place or Habitat for
Humanity) permission to communicate with my current landlord or property manager for the purpose of discussing any and all of
the facts and circumstances of my current tenancy, as well as the other information listed on my application with no limitations or
restrictions regarding what may be discussed or revealed to them. Please provide the requested information below at your earliest
convenience.

_________________________________________________________ ___________________________
Applicant Signature Date

The following information will serve as verification of rent

Landlord Information:

_________________________________________________________ ____________________________
Property Name (Name of Apartments) Address

_____________________________________ _____________ ____________________________

Landlord Printed Name Contact Phone Fax number

_____________________________________ _______________ ____________________________

Landlord Signature Federal ID # or SSI# Date Verified

_____________________________________
Landlord email address

Applicant Rent Information:

$_____________________________________ $_______________ $___________________________

Monthly rent as stated in lease agreement Amount Due Amt. of Interest/late fees included

Are any of these included in the rent amount? Electric $______________

Water $______________

Gas $______________

As landlord or manager, I certify that all information listed on this form is true and correct as outlined above and will be used as
documentation to provide the payment of this applicant’s rent payment.

*RETURN THIS FORM COMPLETED WITH A W-9 FORM SO THAT PAYMENT CAN BE MADE*