City of Foster City Measure K Emergency Rent Relief Eligibility Screening FormAPPLICANT NAMEDATE OF APPLICATIONAPPLICATION NUMBERBMR PROPERTYBMR UNIT #VERIFIED SIZE OF UNITVERIFIED RENTAL RATERENT, UTILITIES, BOTH, DEPOSITAMOUNT REQUESTEDSENIOR (62+), VETERAN, DISABILITY, MINOR CHILD/RENAPPROVEDYES/NOBASIS FOR NEEDCHOOSE 1-9OTHER: DESCRIBEEXTREME HARDSHIPYES/NO - See Award GuidelinesDOCUMENTATION PROVIDEDYES/NOAPPROVEDYES/NOEXPLANATION IF NOFINANCIAL ACCOUNTS BALANCEDOCUMENTATION PROVIDEDYES/NOAPPROVEDYES/NOHOUSEHOLD INCOME PER RECERTLast RecertificationMust have a valid and verifiable need. Attach documentation. Examples include a letter or email from the employer, medical bills or documented evidence of medical issue or injury, paystubs, bank statements showing income reduction, or notarized affidavit. Total balance must be less than $10,000. Checking, savings, stocks, digital wallet balance , etc. (but not 401K, IRA, Pension, Deferred Compensation).FINANCIAL ACCOUNT BALANCE <$10,000INCOME VERIFICATION
TYPE OF REQUESTHOUSEHOLD DEMOGRAPHICSDEMONSTRATION OF NEED ELIGIBILITY AND FUNDING AWARDFOSTER CITY EMERGENCY RENT RELIEF PROGRAM FOR BMR TENANTSMust meet at least one demographic criteria. Documentation of veteran status is required. For disabilities, verification of the fact that the applicant is disabled. Do not ask or seek information about the nature of the disability. Age is verified by ID, Minor children are verified by the Income Certification. v.1 4/25
City of Foster City Measure K Emergency Rent Relief Eligibility Screening FormDATE OF LAST RECERTIFICATIONCURRENT HOUSEHOLD INCOMEHOUSEHOLD SIZEINCOME LIMIT FOR HH SIZE50% AMI per HCDUTILITY ALLOWANCE AMOUNTFor Unit SizeAPPROVEDYES/NOLEASE RECEIVEDYES/NO/PENDINGDEPOSIT AMOUNT YES/NO/PENDING/N/AIDENTIFICATION YES/NO/PENDINGUTILITY BILLS YES/NO/PENDING/N/ALEDGER YES/NO/PENDING/N/AADDITIONAL DOCUMENTS REQ'DYES/NO/PENDING/N/AAPPROVEDAWARD AMOUNTNOTICE TO LANDLORD SENTYES/NO/PENDING W9 RECEIVEDYES/NO/PENDING SDP COMPLETEYES/NO/PENDING NOTICE SENT TO TENANTYES/NO/PENDING Signature of ApproverTitle DateAward GuidelinesKey for Basis of NeedSee County Agreement, Resolution, and Board Memo for more information Guidelines
1-Job loss 2 - pay reduction, 3- medical, 4-disability, 5-caregiver, 6-job loss/job hunting, 7- job loss/training program, 8-can't afford deposit, 9-other (describe) Use HCD income limits and Utility Allowances for current year. City's income limits and UA take effect July 1 each year. Must be based on current household size. Utility Allowance schedule is provided by the County and approved for each BMR property by the City. Recert must be less than 12 months old or income must be recertified.Verify rental rate, current lease, deposit amount, if applicable. Request ledger if needed to verify late payments, nonpayment. Also verify utility bills if paid to landlord. Copies of bills suffice for verification.a) if the applicant applied for rent and utilities, the award amount is the rent plus the greater of utility allowance or utility bills submitted, with a maximum of $3,000; b) if the applicant applied for rent only, the award amount is one month of rent up to $3,000; c) if the applicant applied for a deposit, the award amount is the amount of the deposit as specified by the landlord, up to $3,000. Attach W9 and this form to SPD. Maximum award is $3,000 total per household.
VERIFICATION OF DOCUMENTSAPPROVAL
v.1 4/25