Emergency Rental Assistance Program - Self-Attestation Form - Instructions

Sep 19, 2026

Instructions for completing the Emergency Rental Assistance Program Self-Attestation Form, providing a written statement to support eligibility when required documentation is unavailable. Applicants must select applicable criteria, including household income, financial impact, housing impact, or residence, and complete the household member income table and narrative attestations. The form explains two income determination methods, allowable income sources, and COVID-19 impact and housing risk descriptions. A signed certification, uploaded with the online application, verifies accuracy and may affect processing or assistance limits.

LanguageEnglish

CategoryForms

FormatPDF

Pages7

Reading Time3 min

AccessFree to download

Instructions

Eligibility Criteria

Household Information

Income Determination Methods

Written Attestations

Residence Details

Certification and Warning

Emergency Rental Assistance Program Self-Attestation Form INSTRUCTIONS This is a written statement that permits the documentation of eligibility for the program based on any ONE or MORE of the following criteria: ● Household Income ● Financial Impact (e.g., unemployment, reduction in income, significantly increased expenses, or other financial hardship) ● Housing Impact (e.g., risk of housing instability or homelessness) ● Residence (e.g., proof of residence at an eligible rental unit in the absence of a lease/rental/sublease agreement) Carefully read each section and complete ONLY the applicable criteria sections for which you are unable to provide the required supporting documentation and thus needing to self-attest. Once you have filled out the applicable criteria sections you must sign the certification at the end. The completed and signed certification can be uploaded with your online application [at](at dfs.wyo.gov/erap)[ ](at dfs.wyo.gov/erap)[dfs.wyo.gov/erap](at dfs.wyo.gov/erap). Please note that the use of self-certifications may delay the processing of your application, require additional information from you, or result in limitations to the amount of assistance available to you. If you have any questions about the documentation requirements, visit the program website at [dfs.wyo.gov](dfs.wyo.gov) or feel welcome to call the Contact Center at 1-877-WYO-ERAP between 9am and 6pm MT, Monday through Friday. Other members of your household (including minors) | FULL NAME (including YOURS) | RELATIONSHIP TO YOU
(Indicate “self” foryour name) | EMPLOYED?
(Y or N) | Annual GROSS INCOME | | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Annual gross income from all sources (total of all members) | | | | Household income is determined using one of the two following methods: ▪ 2020 ANNUAL INCOME: Sum of all your rental household members’ income for calendar year 2020 using the Adjusted Gross Income (AGI) as noted on your Internal Revenue Service (IRS) Form 1040 series for individual Federal annual income tax purposes; or ▪ RECENT ANNUAL INCOME: Sum of all your household members’ income in the last two months and multiplied by 6. If this method is used to determine income eligibility, applicants will need to recertify their income every 3 months for any award extensions applied for by the applicant. Sources of income may include: salary, wage, tips, commissions, business income, interest, dividend, social security benefit, annuities, insurance, Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits, unemployment and disability compensation, worker's compensation and severance pay, and Welfare assistance payments. WRITTEN ATTESTATION OF LACK OF INCOME DOCUMENTATION Please detail the circumstances that do not permit the applicant to complete the 1040 Tax Return and/or provide the documents necessary to complete an income eligibility review: WRITTEN ATTESTATION OF COVID-19 FINANCIAL IMPACT Please describe how you or one or more individuals within the household has experienced a reduction in household income, incurred significant costs, or experienced other financial hardship due, directly or indirectly, to the COVID-19 outbreak: WRITTEN ATTESTATION OF COVID-19 HOUSING IMPACT Please describe how you or one or more individuals within the household is currently at risk of experiencing homelessness or housing instability due to unsafe or unhealthy living conditions or other evidence of risk.; WRITTEN ATTESTATION OF RESIDENCE Please provide information about your rental unit and landlord | Rental Unit Address | | | --- | --- | | Address 2 | | | City | | | Zip Code | | | Name of Landlord | | | Landlord Email Address | | | Landlord Phone Number | | | Monthly Rent Owed | |

FAQs

What can applicants self-attest when they lack supporting documents?

Applicants may self-attest eligibility based on one or more criteria: household income, financial impact, housing impact, and residence. The form instructs completing only the applicable sections where documentation cannot be provided.

How is household income determined for eligibility purposes?

The form provides two methods: using 2020 annual income based on IRS Form 1040 AGI, or using recent annual income calculated from the last two months multiplied by 6. If the recent method is used, income must be recertified every 3 months for extensions.

What does the applicant certification require and what are the consequences?

The applicant must sign the certification declaring the statement is true and correct under penalty of perjury and agree to provide additional information on request. The form warns that provided information is subject to verification and that false or fraudulent statements can be considered felonies with assistance potentially terminated.

Sep 19, 2026

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