Fillable Wisconsin Emergency Rental Assistance (WERA) Program Request for (Community Action)

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Wisconsin Emergency Rental Assistance (WERA) Program Request for (Community Action)

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The Wisconsin Emergency Rental Assistance (WERA) Program Request for (Community Action) form is 2 pages long and contains:

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  • 0 check-boxes
  • 69 other fields

Country of origin: US
File type: PDF

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Rev
: 3/1/2022 Page 1 of 2
Wisconsin Emergency Rental Assistance (WERA) Program
Request for Assistance / Renter’s Verification
Please return this form to .
This document provides a way for the landlord/rental agent to verify the terms of tenancy of the applicant. This
document can be used in the place of providing a written lease I but does not replace a written lease between the
tenant and landlord. If this form is utilized, it must be completed and signed by the landlord/rental agent.
Applicant Name
Unit Address
City, State, Zip
Phone
Email
Total Assistance
Requested
$
Description of
Assistance Requested
For recertification
only
I certify that my income my circumstances have not changed, and I am in need three (3)
additional months of rental assistance.
Te
nancy Information:
Property Owner
Manager/Rental Agent
Address
City, State, Zip
Phone Fax
Email
For recertification only I certify that the tenancy information has not changed.
Ren
tal Agreement Information:
Rent Amount $
Total Past Due Rent $
Rent Due
☐
weekly
☐
monthly
☐
other (Click or tap here to enter text.)
Type of tenancy
☐
one year (term: Click or tap here to enter text.)
☐ months (term: Click or tap here to enter text.)
☐ month-to-month (start date: Click or tap here to enter text.)
☐ week-to-week (start date: Click or tap here to enter text.)
Payment method for
heat and electric
Heat
☐ Included in the rent
☐ Separate Payment is made to the
Landlord
☐ Tenant pays directly to utility vendor
Electric
☐ Included in the rent
☐ Separate Payment is made to the
Landlord
☐ Tenant pays directly to utility vendor
For Recertification Only
I agree to accept three additional months of rent for the above names tenant. I
understand that I may not evict the applicant for non-payment of rent during the
time rent assistance is provided.
Rev
: 3/1/2022 Page 2 of 2
By typing my name in the ‘Agency/Landlord Agency Signature’ field, I indicate that I am the person named, and this entry is the l
egal
equivalent of a manual/handwritten signature. I further understand that I may print out the document and sign by hand. I
understand that all information and supplemental documentation may be subject to verification. I understand that providing
application information I am authorizing the Wisconsin Department of Administration and its authorized agents to verify the data
provided against federal, state, county, energy provider, water utility, employer and landlord databases and records.
Signature of owner, landlord or rental agent
Date
Signature of applicant
Date
Emergency Rental Assistance: Completed by WERA Staff Only:
Crisis
Months Covered
Total Amount
Rent Assistance Arrears
$
Rental Assistance Needed
$
Lot Assistance Arrears
$
Lot Assistance Needed
$
Late Fees
$
Internet
$
Water
$
Security Deposit
Count as one month
$
Other Housing Costs (list
each, count as one month)
$
$
$
$
$
Housing Stability Services
Count as one month
$
Other Information
Please describe any other information about crisis(s) and case.
Total WERA Assistance
$
$
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Wisconsin Emergency Rental Assistance (WERA) Program Request for (Community Action)

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Completed 7 June 2022

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