Please enable JavaScript in your browser to complete this form. - Step 1 of 5Virginia Rent and Mortgage Relief Program (RMRP) TENANT/HOMEOWNER APPLICATIONIf you have not already completed an intake application for NRCA services, please start with the online form at https://newrivercommunityaction.org/application-for-nrca-services/ to provide individual/family details required for assistance. The Tenant/Homeowner must have experienced a loss of income due to the COVID-19/Coronavirus pandemic for RMRP. All applicants will need a copy of their lease or mortgage statement, current income verification, and have a COVID related cause. Date of Application *Today's DateHOUSEHOLD INFORMATION Please enter the following information for the primary tenant/homeowner:Name *FirstLastAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProperty Name (if applicable):County/City *Floyd CountyGiles CountyMontgomery CountyPulaski CountyRadford City Phone *EmailTotal Household Monthly Gross Income *The determination of income includes any unemployment insurance received by a member of the household but does not include one-time payments such as a stimulus check. Number of Individuals in HouseholdAges 0-8Ages 9-17Ages 18-24Ages 25-34Ages 35-44Ages 45-54Ages 55-64Ages 65 & overTOTAL Number in Household *The Tenant/Homeowner has experienced a loss of income due to the COVID-19/Coronavirus pandemic. Please select the reason(s) for loss of income below:Laid offPlace of employment has closedReduction in hours of workMust stay home to care for children due to closure of day care and/or schoolReduction or elimination of child or spousal supportNot able to work and/or missed hours due to contracting COVID-19Unable to find work due to COVID-19Unwilling or unable to participate in previous employment due to high risk of severe illness from COVID-19Other Other loss of income due to COVID - Please describe: NextTenant’s Monthly Rent/Homeowner’s Mortgage Monthly Payment AmountRMRP payment for rent includes fees and utilities that are charged to the tenant as part of the rent and listed within the lease agreement. RMRP payment for mortgage excludes property taxes and homeowners insurance.Number of Bedrooms in Rental Unit *Amount of Past Due Rent/Mortgage Owed *(Enter the amount of past rent/mortgage due for each month and indicate total amount)April AmountMay Amount June Amount July Amount August Amount September AmountOctober AmountNovember Amount December AmountCurrent Month’s Amount of Rent/Mortgage Due *TOTAL AMOUNT of Rent/Mortgage Needed and Requested from RMRP *(Amount of Past Due Rent/Mortgage Owed + Current Month’s Amount of Rent/Mortgage Due)PreviousNextPlease enter the following information for the primary tenant/homeowner:Race (check only one) *Multi-RacialAmerican-Indian or Alaska NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhiteDon't know/refuse to answerEthnicity *Hispanic or LatinoNon-Hispanic or LatinoDon't know/refusedPreviousNextFile Upload Click or drag a file to this area to upload. If able to attach documentation or photo of document, upload here. Note that unclear photos may be requested again. Supporting Documentation is Required. Please check all that apply. Lease (only the pages of the current lease that specify the tenant’s information, rent amount, and all signatures)Tenant Ledger and Associated FeesOtherOther Income Verification Describe other income verification if not listed. Upload file documentation or picture of the document if possible. Income verification is required. Upload file if possible. *Check stubs from employerLetter from employerBank statementUnemployment insurance statementSSI/SSDI verificationChild support/alimony verificationZero Income Certification PreviousNextTENANT/HOMEOWNER CERTIFICATIONCertificationBy checking, I certify that the information I have provided in applying for RMRP assistance is true, accurate, and complete. Additionally, I certify that I have not received any other form of subsidy, financial assistance for rent during the same time period with CARES Act, or other federal, state, or local funding.Type in your name as electronic signature:Submit
