Wisconsin Emergency Rental Assistance (WERA) Program
Income and Housing Attestation
Shaded area to be completed by WERA agency.
Please return this form to .
Eligible clients (i) qualified for unemployment benefits or (ii) experienced a reduction in income, incurred
significant costs, or experienced other financial hardship during the pandemic that threaten the
household’s ability to pay the costs of the rental property when due.
I hereby certify that the information given is complete and accurate to the best of my knowledge.
I understand that I may be required to present records and documents to support the information provided. I
understand that inaccurate or incomplete information reported could cause my rental/utility assistance
benefit(s) to change. By typing my name in the ‘Applicant Signature’ field, I indicate that I am the person
named, and this entry is the legal equivalent of a manual/handwritten signature. I further understand that I
may print out the document and sign by hand.
Applicant Signature Date Signed
Applicant First and Last Name
Income Type impacted during the pandemic:
Please check why income was impacted:
Business Closed Seasonal Job Hours Cut Furlough Laid Off Schools Closed
Rise in Basic Living Costs* Other (Please explain):
*Example: clothing, diapers, cleaning supplies, personal hygiene products, fuel, etc.
Self-Attestation: Please describe your situation.
Please acknowledge by checking the box, that you have been unable to pay rent/utilities and are at risk of
losing your housing or facing eviction.
Please acknowledge by checking the box, that you have been not receiving other federally funded
emergency rental assistance.
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signature
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