1. APPLICANT INFORMATION: Provide your legal name, an address where you receive your mail, an e-mail address (if applicable), your date of birth, and your marital status and other fields.

2. CO-APPLICANT/OTHER HOUSEHOLD MEMBER INFORMATION: List all other members of the household residing in the unit that are 18 years of age or older. Attach additional sheets if necessary.

4. HOUSEHOLD COMPOSITION AND CHARACTERISTICS: As of today, 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, date of birth and marital status. Indicate if any of the members listed are disabled and explain if there are any expected additions to the future household, e.g. birth of a child, adoption, legal custody ruling resulting in an additional household member.

6. ELIGIBILITY INFORMATION: The information collected here is important to determine eligibility as it relates to emergency assistance.  

7. COVID-19 INFORMATION: Provide basic information concerning eligibility related to the public health emergency with respect to COVID-19.  Provide information on whether you or a household member were directly affected by COVID-19.

a. Agreement to turn over Proceeds; Future Reassignment.

If the applicant has received or receives any Proceeds from any source that covers the expenses covered by the Covid-19 housing assistance provided, the applicant agrees to promptly pay such amounts to the County.  

b.  In the event that the applicant received, receives or is scheduled to receive any Proceeds not previously disclosed to the County the applicant shall notify the County of such Subsequent Proceeds, and the County will determine the amount, if any, of such Subsequent Proceeds that are a duplication of benefits (DOB). Subsequent Duplication of Benefits proceeds shall be disbursed as follows:

(1)      If the Award has been fully expended by the County, any Subsequent DOB Proceeds shall be paid by applicant to the County up to the amount of the Award.

(2)      If no portion of the Award has been expended by the County, any Subsequent DOB Proceeds shall be paid by applicant to the County and used to reduce the Award. If the application of the Subsequent DOB Proceeds would reduce the Award to zero, all Subsequent DOB Proceeds and any funds previously paid by the applicant to the County shall be returned to the applicant, and this Agreement shall terminate.

(3)      If some portion of the Award has been expended by the County, any Subsequent DOB Proceeds shall be used, retained and/or disbursed in the following order: (1) Subsequent DOB Proceeds shall first be paid by applicant to the County to reduce the unexpended portion of the Award; (2) if the application of the Subsequent DOB Proceeds would reduce the unexpended Award to zero, any remaining Subsequent DOB Proceeds shall be applied to expended portion of the Award and retained by the County; (3) if the application of the Subsequent DOB Proceeds reduces both the unexpended and the expended portions of the Award to zero, any remaining Subsequent DOB Proceeds shall be returned to the applicant, and this Agreement shall terminate.

(4)      If the County makes the determination that the applicant does not qualify to participate in the Program or the applicant decides not to participate in the Program, the Subsequent DOB Proceeds and any funds previously paid by the applicant to the County that have not been used or obligated by the Program shall be returned to the applicant, and this Agreement shall terminate.

(5)      Once the County has recovered an amount equal to the Award, the County will reassign to applicant any rights assigned to the County pursuant to this Agreement.

8. PROPERTY INFORMATION: Provide information about the rental payments and past due information.

9. OTHER ASSISTANCE RECEIVED: Provide all information regarding any other types of assistance received related to the COVID-19 pandemic.

10. INCOME INFORMATION: 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 other income for all household members. Food benefits are NOT considered income. Also, federal unemployment benefits under the CARES Act are classified as stimulus funds, not unemployment benefits. These funds are specifically excluded from the income calculation.

12.  FALSE STATEMENTS: Chapter 817 of the Florida Statutes provides that willful false statements or misrepresentation concerning income and assets or liabilities relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under §775.082 or 775.083.

Applicant is hereby notified that intentionally or knowingly making a materially false or misleading written statement relating to the Program could result in ineligibility for benefits, action to recover any Program benefits paid to or on behalf of applicant, and/or a referral to criminal law enforcement. Applicant represents that all statements and representations made by applicant regarding Proceeds received by applicant have been and shall be true and correct.

13. ELIGIBILITY RELEASE: It is required that you sign this form, which allows the Subrecipient, State or Vendor to request information from Third Parties if it chooses to do so, concerning your eligibility and participation in this program. This form allows for income, assets, child support, etc. to be verified and documented.

14. LOSS OF INCOME:

I/We (declare to be true) that I/we am an Indian River County Resident that was employed and has had a loss of income resulting from COVID-19 on or after March 1, 2020 due to temporary furlough/layoff, elimination of position, reduction of work hours, or self-employment with temporary closure or loss of business.  

15. PUBLIC RECORDS DISCLOSURE AND ACKNOWLEDGMENT:

Information provided by the applicant(s) may be subject to Chapter 119, Florida Statutes, regarding Open Records.

Information provided by you/your household that is not protected by Florida Statutes can be requested by any individual for their review and/or use. This is without regard as to whether or not you qualify for funding under the program(s) for which you are applying. Having been advised of this fact prior to finalizing the application for assistance or supplying any information, your signature below indicates that:

I/We agree to hold harmless and indemnify the County, any governmental agency, its officers, employees, stockholders, agents, successors and assigns from any and all liability and costs that may arise due to compliance with the provisions of Chapter 119, Florida Statues.

 I/We agree that the County does not have any duty or obligation to assert any defense, exception, or exemption to prevent any or all information given to the County in connection with this application, or obtained by them in connection with this application, from being disclosed pursuant to a public records law request.

I/We agree that the County does not have any obligation or duty to provide me/us with notice that a public records law request has been made.

I/We agree to hold harmless the City /County or any governmental agency, its officers, employees, stock holders, agents, successors and assigns from any and all liability that may arise.