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COVID-19 Impact - Statement of Fact

 

If you are unable to pay your rent due to a COVID-19 impact but do not have formal documentation to provide (pay stubs/payroll), please describe your situation below. Please provide as much support documentation as you can (text message from employer, your name on schedule, etc.) along with this statement.

 

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Certification of Statement:

Under penalty of perjury, I certify this information in this certification is true and correct to the best of my knowledge. I understand that providing false representations herein constitutes as an act of fraud.

 

Name: _________________________________    Date:________________________________


 

Signature: _____________________________________________________________________

 

 

 

 

 

 

 

Impacto de COVID-19 - Declaración de Hecho

 

Si usted no puede pagar su renta porque ha sido impactado por COVID-19 pero no tiene documentacion formal que pueda proveer (talones de cheque, nómina de sueldos) por favor describa su situación lo mejor que pueda. Por favor incluya otros documentos que puedan apoyar su declaración (mensaje de texto de su empleador, foto de su nombre en el calendario de trabajo, etc.).

 

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Certificación de declaración:

Bajo pena de perjurio yo declaro que esta información es verdadera y correcta según mi leal saber y entender. Entiendo que en proveer información falsa en este documento puede constituir en un acto de fraude. 

 

Nombre:______________________________________ Fecha: _____________________________

 

Firma: ____________________________________________________________________________