6. Are you receiving rent assistance from another organization that is paying
your rent in full? ………………………………………………………………………
Please list all sources and phone numbers of rental or utility assistance your household is
currently receiving, if applicable:
7. DEMOGRAPHIC INFORMATION
Primary Tenant’s Full Name:
Race/Ethnicity (check one)
Black / or African American
Native Hawaiian or Other Pacific Islander
Hispanic/ Latino Ethnicity (check one) ……………………………...…...…….
8. Is anyone in your household currently unemployed and have been
unemployed for more than 90 days due to loss of employment? ………………
9. Do you have any outstanding utility or internet bills? ………………………....…
If Yes, please provide documentation to your landlord.
10. Do you use internet to engage in distance learning, telework, telemedicine,
or obtain government services? …………………………………………..……….
11. Are you related to your landlord? ……………………………………………..……
APPLICATION CERTIFICATION:
I certify under criminal penalty under the law of Utah that the information I provided on this application
is true and correct. I understand that if any of the information is false or inaccurate, I may be
responsible to repay any funds received.
I understand the Department of Workforce Services conducts reviews of rental assistance, even after
payments have been made. These reviews are designed to determine the accuracy and quality of
eligibility decisions made, and the accuracy of payments made. Applicants and recipients of rental
assistance may be asked to cooperate with these reviews which may include requests for additional
information. By participating in this program, you are agreeing to provide complete and accurate
information requested as part of a quality control review. Information requested must be provided to
the Department within 10 days of the request.
By signing this document, I consent to the disclosure of my name, contact information, and account
information to my landlord, utility companies, or any organization that may be assisting with my rent
or utility payments for the purpose of determining my eligibility for benefits and services.
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.