CLARK COUNTY 2021 COVID-19 EMERGENCY RENTERS ASSISTANCE PROGRAM (ERAP)

Tenant 2021 Monthly Household Income Self-Attestation

Tenant Applicant Name:

Tenant Property Address:

Tenant Phone: Tenant Email:

TENANT MONTHLY HOUSEHOLD INCOME CALCULATION

TENANT(S) HOUSEHOLD MEMBERS INCOME INFORMATION - To complete this form, fill in ALL INCOME
EARNINGS for EACH TENANT AND HOUSEHOLD MEMBER. Only report the income earned during the 60 days
prior to the date of your application. If you have more than 5 Household Members with an income, please
include additional pages and include in the total Annual Income Amount.

Indicate Month
Household Household Household Household Household
Income Received
Member Member Member Member Member
SOURCE OF INCOME (I.e., January –
(HM) (HM) (HM) (HM) (HM)
February, January
#1 #2 #3 #4 #5
only, etc.)
Income from
Employment
Name of Employer(s)

Type of Business/Title

Self-Employed Profits

Social Security
Retirement/Survivors/
SSI/SSD
Veteran’s Benefits
retirement/disability
TANF-Temporary
Assistance for Needy
Families
Pension

Unemployment
Insurance
Other Income (Name
Sources):

1. ADD ALL OF THE

INCOME AMOUNTS
FOR EACH COLUMN.

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2. TOTAL 2021 HOUSEHOLD INCOME FOR ALL MONTHS LISTED. Add the total amounts for each Household
Member from 1. Together to calculate the TOTAL HOUSEHOLD INCOME (HM#1 + HM#2 + HM#3 + HM#4 +
HM#5) and insert that amount here:
$ ______________________

3. DECLARATION OF NO INCOME. This section is only applicable if you, your co-tenants, and all Household
Members do not have any income (Total Income in item 2 above is $0.00). I declare under penalty of perjury I
nor any tenant or household member has had income during the 60 days prior to the date of my application.
Initial here: _______

Self-Attestation for Household Income:

If you cannot provide the required documentation for income at this time, please use this section to explain why
supporting documents are not readily available.

TENANT CERTIFICATION
By signing below, I understand that making a false statement or providing false information is subject to civil
and criminal penalties under the laws of the State of Nevada and the United States.

I understand that if I am determined to be eligible for this program, I may be required to submit income
documentation to prove my eligibility at a later time. I acknowledge and understand that Clark County has
provided no warranty or guarantee as to award selection, and I waive any responsibility and liability of the
Clark County, and all of its departments, employees, and elected officials, from damages and losses caused by
my non-selection and waive all errors and failures occurring during the application processing and
transmissions of rental payment.

I declare, under penalty of perjury, that my total household income for

myself and all household members, for the 60 days prior to the date of my $
application for assistance is:
TENANT APPLICANT IS OVER 18 YEARS OF AGE AND SIGNS UNDER PENALTY OF PERJURY UNDER THE LAWS
OF THE STATE OF NEVADA THAT THE INFORMATION PROVIDED FOR ALL HOUSEHOLD MEMBERS IS
COMPLETE, TRUE AND CORRECT.
Signature Printed Name Date

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