Statement of Delinquent Rent

Tenant Name: __________________________________

Address of Rental Unit: __________________________
This notice is to inform you that I have not received rent due for the months of:
____ March 2020 (Note: The GRA will not provide assistance for any period prior to March 13,
2020.) (Please do not select any future months)

____ April 2020 ____ April 2021 _____April 2022

____ May 2020 ____ May 2021 _____May 2022
____ June 2020 ____ June 2021 _____June 2022
____ July 2020 ____ July 2021 _____July 2022
____ August 2020 ____ August 2021 _____August 2022
____ September 2020 ____ September 2021 _____September 2022
____ October2020 ____ October2021 _____October 2022
____ November 2020 ____ November 2021 _____November 2022
____ December 2020 ____ December 2021 _____December 2022
____ January 2021 ____ January 2022
____ February 2021 ____ February 2022
____ March 2021 ____ March 2022

1) The base rent amount not paid for the months checked above is $ _________
2) Late fees applied to the unpaid rent total $ _____________
(Note: The GRA program will not pay late fees that exceed 8% of the total past due rent. You will be required to
waive any late fee above the percentage allowed.)

3) Total Amount of past due rent and late fees requested: $_________
I, _____________________(Landlord) certify that the amounts listed above is what I am owed
for ____________________(Tenant) residing at ______________________________________
______________________________________________ (Street Address, City, State, Zip Code).
I affirm that all the information is true, correct and complete to the best of my knowledge.
In signing this statement (including electronic signature) you are acknowledging that falsification
of documents or any material falsehoods or omissions in the Application, including knowingly
seeking duplicative benefits, is subject to state and federal criminal penalties. You are particularly
put on notice that 18 U.S.C. §1001 provides, among other things, that whoever knowingly and
willingly makes or uses a document or writing containing any false, fictitious, or fraudulent
statement or entry, in any matter within the jurisdiction of any department or agency of the
United States will be fined not more than $10,000 or imprisoned for not more than five years, or
both.
 Statement of Delinquent Rent

____________________ ______________
Landlord Signature Date