Rental Assistance Request Letter

RENTAL ASSISTANCE REQUEST LETTER

RECITALS

WHEREAS, Applicant Name: currently occupies the residential premises located at Property Address: ; and

WHEREAS, Landlord/Owner Name: is the owner or property manager with whom Applicant has an existing rental agreement dated Lease Date: ; and

WHEREAS, Applicant seeks financial assistance to prevent eviction and to maintain stable housing by requesting assistance for rent due for the period described below.

REQUEST SUMMARY

SCOPE OF ASSISTANCE

The Applicant requests payment of rental charges as set forth below. The assistance, if provided, shall be used solely for rent, late fees (if applicable and authorized below), and other housing-related charges expressly listed in this request. Applicant affirms that funds received will not be used for non-housing purposes.

PAYMENT TERMS

Applicant acknowledges that the assistance amount requested is limited to the specific rent obligations identified below. Payment is requested for Rent Due From: through Rent Due To: .

Disbursement Method: . Payment Schedule/Timing:

Late Fee Authorization (if applicable): Late fee percent: ; Grace period (days): .

Applicant represents that any assistance paid in accordance with this request will be applied to the outstanding rent obligations and that Applicant will provide documentation of application of funds upon request by the payer or disbursing entity.

TERM AND TERMINATION

Effective Start Date: . Anticipated End Date: .

Either party may terminate or withdraw this assistance request prior to disbursement by providing Notice Period (days): days written notice to the other party. Termination of this request does not relieve Applicant of obligations arising under any separate lease between Applicant and Landlord.

CONFIDENTIALITY

All personal, financial, and tenancy information provided in connection with this request is furnished for the purpose of evaluating eligibility and disbursing assistance. Such information will be treated as confidential and used only for processing the assistance request, verifying eligibility, administering payments, or as required by law. Applicant consents to the limited disclosure of necessary information to the disbursing entity, verifiers, and Landlord for these purposes.

Applicant consents to disclosure of information as described above

GOVERNING LAW; ENTIRE AGREEMENT

This request and any assistance disbursed pursuant to it shall be governed by the laws of the state in which the Property Address is located. This document contains the entire agreement between the Applicant and the Landlord/Owner regarding the subject matter herein and supersedes any prior oral or written statements specifically concerning rental assistance requested by Applicant.

SUPPORTING DOCUMENTATION

Submit the following documents with this request (check all that apply):

Lease agreement Proof of income or unemployment documentation Government-issued ID Notice of eviction or notice to pay rent

CERTIFICATION

By signing below, Applicant certifies under penalty of perjury that the information provided in this request and the supporting documentation is true, complete, and accurate to the best of Applicant's knowledge. Applicant understands that knowingly submitting false information may result in denial of assistance and potential legal consequences.

ADDITIONAL REMARKS

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