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Step One

Landlord Name (First, Last)*
Landlord Phone Number*
Landlord FRJC Number*
As listed on your Rental Housing Fee invoice
Landlord Email Address
Please select the reasons for which you have experienced financial hardship caused by the COVID-19 pandemic*
1. Tenants unable to pay rent
2. Reduction in work hours (please provide employer contact information below)
3. Layoffs or terminations due to COVID-19
4. Increase in out-of-pocket medical expenses
5. Other (please explain below)
Check all that apply.
Other (please explain below)
If you selected "Other" for the question above, please describe the reason for financial hardship caused by the COVID-19 pandemic.
Employer Name
Employer Address
Contact Person
Employer Phone Number
Employer Email Address
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When do you anticipate is the soonest you would be able to pay the amount due on your invoice?*
Please explain.
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Attach Supporting Documentation
You must provide written documentation in support of the claim of financial hardship related to COVID-19. The types of documentation that are acceptable include, but are not limited to, a letter or notice from tenants, establishing proof of their inability to pay rent, letter from employer, establishing proof of reduction in work hours or proof of employer/business shut down due to COVID-19, medical bills, etc. If Landlord is self-employed, please provide proof of self-employment including federal income tax returns and a signed explanation of the hardship.
SUPPORTING DOCUMENTATION*
ADDITIONAL SUPPORTING DOCUMENTATION
(If necessary)
ADDITIONAL SUPPORTING DOCUMENTATION
(If necessary)
ADDITIONAL SUPPORTING DOCUMENTATION
(If necessary)
Declaration Under Penalty of Perjury
I swear or affirm that the answers are true and reflect my current finances and status regarding COVID-19. I declare under penalty of perjury under the laws of the State of California that the foregoing, and all attached pages including supporting documentation, are true and correct to the best of my knowledge.
Signature*
Date*
Date
Affirm Signature (Check the box below)*
1. By typing my name into the box above, I affirm that this is my signature for all legal purposes.

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