GDPM

RESIDENT HARDSHIP

EXEMPTION REQUEST

Resident Name:_________________________________________________________________

Phone Number:_________________ Address:________________________________________

I am currently paying the minimum rent of $50.00 to GDPM. In my opinion my hardship is: _______ Long Term (90 Days) ______ Short Term (less than 90 days)

I am requesting a hardship from the payment of my rent because (please mark whichever of the following applies to you):

____	My family has lost eligibility or is awaiting an eligibility determination for a Federal, State, or local assistance program.(this includes a family member who is a non-citizen lawfully admitted for permanent residence)

____	My family would be evicted because I am unable to pay the minimum rent

____	My family’s income has decreased because of a change in circumstances

____	A death has occurred in my family

____	Other (Please list any other reasons):__________________________________________

____________________________________________________________________________

____________________________________________________________________________

Residents requesting a hardship are to provide documentation to the manager, including the reason(s) benefits were terminated and the date benefits were last paid.

Documentation or proof of the above statements (choose one) _____ has been or _____ will be provided to my manager regarding this request.

I realize that all documents provided must meet GDPM’s approval. I also understand that a hardship will not be approved if my family’s OWF (government monetary assistance/welfare) benefits have been reduced or sanctioned due to fraud, failure to participate in an economic self-sufficiency program, or failure to comply with a work activities requirement.

Families who have exhausted OWF (government monetary assistance/welfare) benefits due to the expiration of lifetime time limits will be granted a hardship upon receipt of verification by GDPM’s recertification specialist.

I understand that for the next 90 days GDPM may not terminate my lease for non-payment of rent.

I also understand that during this 90-day period my rent is suspended and that if no hardship is found or if the hardship is determined to be only temporary in nature, then I will need to make payment of all monies due that have accumulated during this 90-day period.

I also understand that although rent is suspended during this 90 days, all my other duties and responsibilities listed in my lease are still in effect. If I do not adhere/follow the other required lease items, I can be evicted during the 90-day period.

I am certifying that all the information I have provided is true. I understand that if I provide fraudulent information, I may be subject to prosecution under Federal law for fraud and subject to repayment of all monies due to GDPM.

Signed this ______________ day of _______________________.

__________________________________ _____________________________________

Head of Household	Other Adult Members

__________________________________

Other Adult Members

__________________________________________________ Dated:______________

Received by (GDPM staff)

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For office use only below this line

______ Hardship exemption request has been approved and a copy forwarded to Recertification

_____ Temporary

_____ Long term:

If hardship information not previously offered at time of initial hardship:

Retro effective date of application::______________________________

______ Hardship exemption has been denied.

Request processed by:_________________________________ Date:_______________

Notice mailed to Resident on _______________________.