Polk CARES 2020

Application Instructions

Please read all instructions for this application. All household members who are 18 years old, or older, must sign and date the application.

Instructions

1. Eligibility

   To be eligible for the Mortgage and Rental Housing Assistance Program, you must meet the following requirements:

   • Current resident of Polk County (excluding those within the city limits of Lakeland and Winter Haven). To see if you live within those city limits, go to Winter Haven address check, or Lakeland address check
   • Provide proof of delinquent rent or mortgage payment
   • Provide proof of loss or reduction of income, loss of employment or health related issues due to COVID-19
   • Current combined gross household income is below 120 percent of median income based on family size

2. Applicant Information

   Provide the legal name of the applicant and co-applicant, an address where you reside and receive mail, an e-mail address, telephone number and emergency contact information. Provide current/last employer, phone number, physical address, supervisor’s name, rate of pay, position, start date and end date. Provide your employment status, annual gross income before COVID-19 and provide brief summary of your hardship.

   Household Size	1	2	3	4	5	6	7	8
   Monthly Gross Income	$4,120	$4,710	$5,300	$5,880	$6,360	$6,830	$7,300	$7,770
   Annual Gross Income	$49,440	$56,520	$63,600	$70,560	$76,320	$81,960	$87,600	$93,240

3. Household Members

   As of Aug. 5, list the current Head-of-Household and all other members of the household. Indicate the relationship of each family member to the Head-of-Household, gender, race, date of birth and marital status. Indicate if any of the members listed are disabled, veterans, or homeless. Race and ethnicity is collected for reporting purposes only.

4. Household Income Verification

   Provide information on all household income sources. Income includes the following: Wages, salaries and tips, alimony, child support, military income, part-time income, temporary income, TANF, Social Security, other benefits and income for all household members over the age of 18. Food benefits are NOT considered income.

5. Asset Information

   Provide the requested information on assets for all household members. Examples of what constitutes assets are listed below.

   • Cash held in savings, checking accounts, safe deposit boxes, homes, etc.
   • Stocks, bonds, treasury bills, CDs, mutual funds, money market accounts, and other investment accounts
   • Individual retirement accounts, 401(k), Keogh accounts, and other similar retirement savings accounts
   • Cash value of life insurance policies available to the holder before death
   • Personal property that is held for investment purposes
   • Equity in real property
   • Retirement and pension funds
   • Mortgage or deeds of trust held by the applicant

6. Housing Request

   Specify the type of assistance requested and provide past due and current payment, company name and address, phone and email address of mortgage company or rental agent.

7. COVID-19 Impact

   Provide information on whether you or a household member was directly affected by COVID-19. Declare whether your household received Polk CARES funds.

8. Required Documents

   Upload the required documents to your application.

   • Valid Florida photo identification or valid Florida driver’s license for all adult household members (18 years of age or older)
   • Proof of loss of income related to COVID-19 impacts due to health and/or employment (Unemployment statement, letter from employer, medical letter)
   • Recent water, electric, utility bill statement dated within the last 60 days (Spectrum, Frontier and Comcast cable bills are not considered a utility)
   • Last 30 days of recent pay stubs or last pay stub issued
   • If renter - Current rental lease/rental agreement which must include the tenant’s name, address of property and landlord/management company name
   • If renter - Landlord verification form and W9 form
   • If homeowner - Current mortgage statement from mortgage company/servicer which must include the borrowers name, address of property and primary account number
   • If homeowner - Mortgage Verification form and W9 form

By submitting an application you are attesting that:

• The applicant(s) certifies that all information in this application, and all information furnished in support of this application, is given for the purpose of obtaining funding under the Polk County’s CFR Mortgage and Rental Assistance Program.
• I/we certify that the application information provided is true and complete to the best of my/our knowledge. By signing this application to verify the information contained, the applicant authorizes the County or any of its duly authorized representatives to verify the information listed herein.
• I/we understand that Florida Statute Chapter 817 provides that willful false statements or misrepresentations concerning income, asset, or liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and imprisonment provided under sections 775.082 and 775.083, Florida Statutes. I/we further understand that any willful misstatement of information will be grounds for disqualification.
• I/we understand this eligibility release, authorizes the County or any of its duly authorized representatives to obtain information from third parties regarding my/our eligibility and continued participation in the CRF Program for disaster assistance.
• I/we agree to provide any documentation needed to assist in determining eligibility and am aware that all information and documents provided, except as exempted pursuant to law, are a matter of public record.
• I/we further grant permission and authorize any employer or other public or private agency to disclose information deemed necessary to complete this application (to include landlord and mortgage verification).

Polk County does not discriminate on the basis of race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital status, national origin, ancestry, source of income, familial status, disability, genetic information, age, citizenship, primary language, or immigration status in the access to, admission into, or employment in, housing programs or activities.