CDC Tenant Declaration

Updated - March 29, 2021:

The Federal CDC extended its eviction moratorium through June 30 for covered persons. Covered persons MUST complete this form and present it to their landlord to avoid eviction. We strongly suggest tenants keep a copy for themselves, get a copy to their attorney if they have one, and get a copy to the court if they are currently involved in an eviction matter.

Eviction Protection Declaration (cdc.gov)

Tenants can qualify only if they can honestly check off any box in BOTH columns A and B, as well as ALL boxes of the Declaration.

ANY item in Column A: 

  • 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) • Supplemental Security Disability Income (SSDI)

 AND ANY item in 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 expenses

AND ALL items in the declaration:

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. 
  • 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. 
    • I understand that after I sign: 
      • Unless I come to an agreement with my landlord, I am still responsible for rent, back rent, and any fees, penalties or interest under my lease. 
      • I must still follow the conditions of my lease. 
      • Unless I come to an agreement with my landlord, if I fail to make my required payments, I could be evicted when this temporary halt of evictions ends. 
      • I can still be evicted for reasons other than not paying rent or not making a housing payment
    • I sign this declaration 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.