Tenant Attestation for Eligibility of
The Landlord Compensation Fund
I, _______________________,( tenant full name) certify under penalty of perjury, pursuant to
ORS 162.065, that the foregoing statements and information is true and correct. I understand
providing false statements is a crime and punishable under Oregon law.
AF
T
The information requested in this form will be used to determine the eligibility of my past due
rent for coverage through the Landlord Compensation Fund Program. Only my landlord may
initiate an application for this program and a completed application does not assure a funding
award. This document and a Declaration of Financial Hardship are required for my past due
rent to be considered for coverage in my landlord’s application for resources. I understand that
the LCF program does not have any income or citizenship requirements. If my landlord chooses
to apply and is selected for funding, and I have provided the required tenant documents, my
past rent owed from April 1, 2020 to current may be covered. I understand this is a competitive
application and funding is not guaranteed even if my landlord does choose to apply. I understand
that independent of my landlord, I have no rights in or obligations owed to me by the LCF
program.
D
R
To qualify for this assistance, the State if Oregon requires the information below to be completed
in its entirety (* = field is optional):
Tenant physical address
*Number of bedrooms in rental unit
Tenant’s current monthly rental amount
$
Estimated total past due rent from April 1,
2020 through present (best estimate).
$
Have you applied for any other forms of assistance that may result in payment of any portion
of the estimated total past due rent listed above?
☐Yes
☐ No
If yes to the previous question, please explain any other forms of rent assistance you have
applied for or have received (otherwise please mark N/A). For example – I have applied for
assistance with my November and December rent through my local Community Action
Agency.
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Oregon Housing and Community Services | 725 Summer St. NE Suite B, Salem, OR 97301-1266 | (503) 986-2000 | FAX (503) 986-2020
LCF Tenant Attestation Form – 1/27/2021
*The State of Oregon is gathering this information to help determine equitable utilization of
this program.
Which of the following describes your racial or ethnic identity (please check all that apply)?
☐Native Hawaiian and Pacific Islander
☐ Hispanic and Latino /a/x
☐ White
☐ Don’t Know / Don’t want to answer
☐ Black and African American
☐ American Indian or Alaskan Native
☐ Asian
☐ A race/ethnicity not listed here
D
R
AF
T
By submitting and signing this attestation, I certify the following:
▪ The above information is accurate to the best of my knowledge.
▪ I have entered into a valid lease agreement with the property owner for the tenant
address listed above on this form. (Lease agreements may be written or verbal but
should include an agreed upon payment for the right to live in the housing unit).
▪ To my knowledge, I am not related to anyone that has ownership rights to my housing
unit. Exception for residents in Resident Owned Manufactured Park Cooperatives.
▪ The property address I have listed on this form is my primary residence.
▪ I have submitted the Declaration of Financial Hardship form to my Landlord or property
owner.
▪ I am the head, co-head or legal representative of this household or their designee.
▪ I understand that I do not need to be a citizen of the United States to receive this
assistance.
▪ I authorize the release of personal information as deemed necessary by the Department
of Housing & Community Services to determine program eligibility and to assure
reasonable program controls. I am aware that I may find additional information on the
types of personal information that may be shared through this program and what that
personal information may be used for. Oregon Housing & Community Services has
posted this on a document entitled Third Party Authorization for the Release of Information
on their website. By my signature I am agreeing to the release of this information for
program use as outlined in that document.
I authorize Oregon Housing and Community Services (OHCS), and any of its authorized
representatives to verify the information provided in this application as true and correct. I
understand that additional information might be required to receive assistance and agree to
cooperate. I also understand that the State of Oregon and/or its agents will use this information
to evaluate my eligibility for assistance, but the State of Oregon and its agents are not obligated
to offer me assistance based solely on the representations in this attestation.
_________________________
Tenant Signature (typed name
is electronic signature)
_________
Date
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Oregon Housing and Community Services | 725 Summer St. NE Suite B, Salem, OR 97301-1266 | (503) 986-2000 | FAX (503) 986-2020