Landlord & Tenant Form

Emergency Rental Assistance Program – Wind River

As Tenant and Landlord, we request that ERAP-WINDRIVER make the following rental
and any utility payments identified below. The Tenant represents, and may be asked to
make a showing, that the Tenant is either recently unemployed or has had financial
difficulties either directly or indirectly due to the current COVID-19 pandemic. All parties
to this application understand and agree that the Emergency Rental Assistance being
applied for can only be provided if ERAP-WINDRIVER has available federal Emergency
Rental Assistance funds, the Tenant and the Tenant’s Housing Unit are eligible for this
program, and the Tenant’s maximum benefits in this Emergency Rental Assistance
program have not been exhausted.
Additional assistance may be provided in subsequent months for future 2021 rent
or utility payments, but additional applications will be required.


Indians and Non-Indians are eligible for this program, but a participating Household
must have income that is less than eighty percent (80%) of the Area Median Income.
Please also note that when making awards of these funds, priority is given to
households that have incomes less than fifty percent (50%) of the Area Median Income.
Tenants, at or subsequent to submitting this Application, are required to submit an
Eligibility Information Statement (“Statement”) as a part of the application process.
The Statement asks for information required by the U.S. Department of Treasury. The
Statement examines income, eligibility for unemployment benefits, the financial impact
of COVID-19, your Household’s risk of homelessness and housing instability, and any
provided written attestations. Both this Application and the Statement will have to be
sworn to by the Tenant. Using this Application, the Statement, and possibly other
documentation, ERAP-WINDRIVER will determine whether the Tenant is eligible for
Emergency Rental Assistance and whether the Tenant’s Household qualifies for priority

Parties and Housing Unit