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TATEMENT OF HARDSHIP v.2.8.4.21 Page 1 of 2
STATE OF GEORGIA RENTAL ASSISTANCE PROGRAM
S
TATEMENT OF HARDSHIP - TENANT ATTESTATION
I or a member of my household, as of / / , am experiencing financial difficulty that is
either due to the COVID-19 pandemic or has taken place on or after March 13, 2020.
My household is experiencing financial difficulty due to (please select the first option that most
applies to your household’s circumstances):
OPTION 1: Qualification for unemployment benefits for at least one household member.
I understand that providing false, incomplete, or inaccurate information on application forms i
n
w
hich assistance has been or will be provided, may result in termination of participation in the
Program, up to 5 years of imprisonment and for each occurrence a fine of up to $10,000.
OR
OPTION 2: At least one household member has experienced a reduction in household income,
incurred significant costs, or experienced financial hardship (please check applicable reason(s)
and include written attestation to describe the financial hardship):
Experienced a loss or reduction of income due to COVID-19.
Needing to take extended time off work due to COVID-19, either to:
Care for my child(ren) whose school is closed; or
Care for a family member who is sick with COVID-19.
Needing to take extended time off work because I have tested positive for COVID- 19.
Excessive COVID-19 related healthcare related or other expenses.
Penalties, fees, and legal costs associated with rent or utility arears.
Payments for rent or utilities made by credit card to avoid homelessness or
housing instability.
Moving costs for households that moved to avoid homelessness or housing
instability.
Increased internet access and computer equipment costs needed to attend work and/or
school.
Alternate transportation for households unable to use public transportation during the
pandemic.
Purchase of personal protective equipment (PPE).
Please briefly describe the financial hardship experienced due to COVID-19, including the name of
the household member that is experiencing the hardship. REQUIRED – Please provide written
description from applicant/effected tenant:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
I understand that providing false, incomplete, or inaccurate information on application forms in
which assistance has been or will be provided, may result in termination of participation in the
Program, up to 5 years of imprisonment and for each occurrence a fine of up to $10,000.