MANATEE COUNTY EMERGENCY RENTAL ASSISTANCE PROGRAM (ERA)

DECLARATION OF HOUSING INSTABILITY

Instructions: Please complete this form if you cannot provide a delinquency notice at this time. (Form to be
completed by the Applicant as listed on the Manatee County ERA application).

Applicant Information:
Applicant Name (Print): Richard Vasger

Address (Print): 1015 12th ave West Lot 11 City: palmetto

Applicant email address is: Aricherlook30@gmail.com

Housing Instability Declaration Information:

I, Richard Vasger , the Applicant, swear or affirm (declare to be true) that

the following option best describes my situation:

☐ Late on rent and the landlord is unable/unwilling to provide a delinquency notice

☐ Paid rent instead of meeting essential household needs (e.g. purchasing food, prescriptions, transportation,
childcare, etc.)
☐ Borrowed from family and/or friend funds to pay for rent or utilities in the past 2 months
☐ Used credit cards or high-interest lenders to pay for rent or utilities in the past 2 months
☐ Received a past due or shut-off notice from your utility company in the past 2 months
☐ Other (Please explain):
Certification:
I am reporting that my housing instability is due, directly or indirectly, to the COVID-19 outbreak for the Manatee
County Emergency Rental Assistance Program to establish my eligibility.
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understand(s) that providing false representations herein
constitutes an act of fraud. False, misleading or incomplete information may result in the termination of the
processing of this application.
I understand that by signing below, I am subject to the provisions of Florida Statutes Chapter 817 Fraudulent
Practices: whomever provides willful false statements or misrepresentations concerning income, asset, or liability
information relating to financial condition is a misdemeanor of the first degree, punishable by fines and
imprisonment provided in s. 775.082 and s. 775.083; s. 837.06 False official statements: Whoever knowingly
makes a false statement in writing with the intent to mislead a public servant in the performance of his or her
official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s.
775.083; and 92.525 Verification of documents; perjury by false written declaration, penalty: A person who
knowingly makes a false declaration is guilty of the crime of perjury by false written declaration, a felony of the
third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
I understand that supporting documentation may be requested at any time to confirm the veracity of statements
made, and failure to provide documentation will result in a denial of assistance.

Richard Vasger 04/21/2023

Signature of Applicant Printed Name of Applicant Date
MANATEE COUNTY EMERGENCY RENTAL ASSISTANCE PROGRAM 1
DECLARATION OF HOUSING INSTABILITY