OMB Control No. 0920-1303
DECLARATION UNDER PENALTY OF PERJURY FOR
THE CENTERS FOR DISEASE CONTROL AND PREVENTION’S
I certify under penalty of perjury, pursuant to 28 U.S.C. § 1746, that the foregoing are true and correct:
I have used best efforts to obtain all available government assistance for rent or housing;1
I either expect to earn no more than $99,000 in annual income for Calendar Year 2020-2021(or no more than $198,000 if filing a joint tax return), was not required to report any income in 2020 to the U.S. Internal Revenue Service, or received an Economic Impact Payment (stimulus check) pursuant to Section 2201 of the CARES Act;
I am unable to pay my full rent or make a full housing payment due to substantial loss of household income, loss of compensable hours of work or wages, lay-offs, or extraordinary2 out-of-pocket medical expenses;
I am using best efforts to make timely partial payments that are as close to the full payment as the individual’s circumstances may permit, taking into account other nondiscretionary expenses;
If evicted I would likely become homeless, need to move into a homeless shelter, or need to move into a new residence shared by other people who live in close quarters because I have no other available housing options.3
I understand that I must still pay rent or make a housing payment and comply with other obligations that I may have under my tenancy, lease agreement, or similar contract. I further understand that fees, penalties, or interest for not paying rent or making a housing payment on time as required by my tenancy, lease agreement, or similar contract may still be charged or collected.
I further understand that at the end of this temporary halt on evictions on March 31, 2021, my housing provider may require payment in full for all payments not made prior to and during the temporary halt and failure to pay may make me subject to eviction pursuant to state and local laws.
Even if you have provided a declaration to your landlord, the Order does not prevent your landlord from seeking a hearing if authorized by State or local law and in accordance with State or local court procedure.
I understand that any false or misleading statements or omissions may result in criminal and civil actions for fines, penalties, damages, or imprisonment.
Signature of Declarant Date
1 “Available government assistance” means any governmental rental or housing payment benefits available to the individual or any household member.
2 An “extraordinary” medical expense is any unreimbursed medical expense likely to exceed 7.5% of one’s adjusted gross income for the year.
3 “Available housing” means any available, unoccupied residential property, or other space for occupancy in any seasonal or temporary housing, that would not violate federal, state, or local occupancy standards and that would not result in an overall increase of housing cost to you.