0920-1303 CDC Eviction Protection Declaration 07APR2021

OMB Control No. 1920-1303
Form Expiration: 09/30/2021

Eviction Protection Declaration
The Centers for Disease Control and Prevention (CDC) has issued an order that may protect you from being evicted or
removed from where you are living. This means that you may be able to stay at the place where you live through
JUNE 30, 2021, if you qualify.

How to use this form
1. See if you qualify for eviction protection under the CDC order. If you’d like help from an expert, contact (800) 569-4287
or go to https://www.hudexchange.info/programs/housing-counseling/rental-eviction/ to get contact information
for a local HUD-approved housing counselor.
2. Sign the declaration that you qualify, on the next page.
3. Give the signed declaration page to the individual or company you rent from (for example, building management,
landlord, etc.). Keep a picture or copy for your records and call your expert back if there’s a problem.

1. Do I qualify?
If you can check at least one box in each column, you qualify.

Column A

AND

I received a stimulus check (Economic Impact
Payment) in 2020 or 2021
I was not required to report any income to the
IRS in 2020
In 2020 or 2021, I earned (or expect to earn)
less than $99,000 as an individual or less than
$198,000 as a joint filer
You are likely to have earned under this
amount if you receive any of the
following benefits:

•

Supplemental Nutrition Assistance Program
(SNAP)

•

Temporary Assistance for Needy Families
(TANF)

•
•

Supplemental Security Income (SSI)

Column B
I cannot pay my full rent or make a full housing
payment because:
My household income has gone
down substantially
I have been laid off from work
My work hours or wages have been cut
I have extraordinary out-of-pocket
medical expenses1
None of the above — You do not qualify.

Supplemental Security Disability Insurance
(SSDI)

None of the above — You do not qualify.

You checked at least one item in each column? Your income level qualifies.
[Check the first box on the next page]

Defined as 7.5% or more of my adjusted gross income for the year

1

CS323605_A

04/01/2021

2. My Declaration that I qualify
By checking the boxes below, I declare that each statement is true.
My income level qualifies for the reasons explained above
I have done my best to make timely partial payments that are as close as
possible to the full payment and to get government assistance in making
my rent or housing payments. 2
If I were evicted, I have no other available housing options, so I would:

• Probably become homeless, or
• Have to move to a homeless shelter, or
• Have to move in with others who live in close quarters.

Troubleshooting
tools for tenants
Find emergency rental
financial assistance
Call (800) 569-4287 to
find a listing for local
HUD-approved housing
counselors

for rent, back rent, and any fees, penalties or interest under my lease.

Report problems with
debt collection
Submit a complaint to CFPB
cfpb.gov/complaint

required payments, I could be evicted when this temporary halt of
evictions ends.

Report discrimination
Submit a complaint.
Call HUD at (800) 669-9777

I understand that after I sign:

• Unless I come to an agreement with my landlord, I am still responsible
• I must still follow the conditions of my lease.
• Unless I come to an agreement with my landlord, if I fail to make my

• I can still be evicted for reasons other than not paying rent or not making
a housing payment.

I sign this declaration3 under penalty of perjury. That means I promise that the statements
above are the truth and that I understand that I can be criminally punished for lying.
You sign here:
Date:

3. Give this signed page to the individual or company you rent from.
ATTN LANDLORDS: Thank you for your compliance. If you violate the CDC’s eviction Order, you and/
or your business may be subject to criminal penalties, including fines and a term of imprisonment.

Calling a local expert is the best way to figure out all the help that is available to you. Find a listing for a local HUD-approved housing counselor by calling
(800) 569-4287.

2

If you have already signed an eviction moratorium declaration, you do not need to submit another one.

3