| Natalia fuentes Motta atest that myself or a member(s) of my household do not have any income. | atest that myself and all members of my household have divulged all income, including all cash payments, and any seitemployment income. attest that myself, or members of my household, have experienced a reduction in income asa result of the COVIO-19 Public Health Emergency. | attest the information| provided is true, accurate, and complete. attest that | and the members of my household hhave occupied the unit for which | am seeking assistance as my primary residence (the home in which | usually live) and have ‘occupied the unit during the period for which rental and/or utility assistance is requested. | attest! will occupy the unit as my primary residence throughout the remaining months for which te assistance is provided. | atest that | have not received, assstance forthe same expenses forthe same months being requested inthis apolication. | understand that any misrepresentaton of information or failure to disclose information requested on this form or creating 2 false or misleading record wil disqualify me from being eligible forthe OUR Florida Program. | also understand the information provided about my household i subject to further verification by the Florida Department of Children and Families, the Department of Treasury, the OUR Florida Program or any other State or Federal agency. By appying for this program, ! authorize verification and may be required to provide supporting documents. l understand f| knowingly make a false claim or statement tothe Federal Government, l may be subject to cul or criminal penalties under 18 U.S.C. 287, 1003 and 31 U.S.C. 3729 as Well as Florida State civil and criminal penalties. oe ‘Signature. fd at pate. O1 (2G 12024.