LANDLORD APPLICATION

The Georgia Department of Community Affairs administers the State of Georgia Rental
Assistance Program (GRA). GRA helps renters with their past due rent and utilities. Payment will
be made directly to landlords and utility providers.

PRE-SCREENING QUESTIONS:
Name of Landlord of Residential Dwelling*: donald russell jr
Do you have one or more tenants in Georgia who are past due on rent or who need assistance
for current rent because of the impact of COVID-19?*: Yes No
What type of property is this?*: Single Family Multi Family Mobile Home
Hotel/Motel
Is this a lease purchase ⁄ rent to own?*: Yes No
Is the unit(s) that you are requesting assistance for supported by any other federally funded
housing or rental program?*: Yes No
Are you the owner of the property?*: Yes No

LANDLORD INFORMATION
Please tell us about yourself in as much detail as possible. (* = required)

Name of Landlord of Residential Dwelling*: donald russell jr

Landlord Email Address*: daviddilley110@outlook.com
Landlord Phone Number*: (201) 890-2043
Landlord Address 1*: 2010 burma rd
Landlord Address 2:
City*: rossville State*: Georgia Zip*: 30741
Landlord Tax Identification Number (Social Security Number/EIN)*: xxx-xx-6325
TENANT INFORMATION:
Please tell us about the tenant in as much detail as possible. (* = required)

Note: Please complete a separate form for each tenant.

First Name*: morgan Middle Name: long Last Name*: danielle

Address 1*: 2010 burma rd
Address 2:
City*: rossville State*: Georgia Zip*: 30741
Email Address*: isbskbsossb@gmail.com
Phone Number*: (256) 626-6773
Is the tenant still residing in this unit? (The Georgia Emergency Rental Assistance program is
only available for tenants that still reside in their unit.)*
Yes No
Total number of people who reside in the residence*: 1
Monthly Rent Amount*: 1900
Amount of past due rent*: 34200
Months Missed*:
Mar 2020 Jun 2020 Sep 2020 Dec 2020 Mar 2021 Jun 2021
Apr 2020 Jul 2020 Oct 2020 Jan 2021 Apr 2021 Jul 2021
May 2020 Aug 2020 Nov 2020 Feb 2021 May 2021 Aug 2021
Has an eviction been filed on this unit?
Yes No
Rent Amount assistance requested for this tenant household.*:
Please check all additional costs that are included in the rent:
Water and Sewer
Gas
Electricity
Trash
Other Energy Cost(s)
Late fees, legal fees, or other charges

SIGNATURE
State of Georgia Rental Assistance Program: Landlord Attestation

This attestation confirms that rents from me at , and that I, , own or

manage the property. I confirm that , the tenant is past due on the rental amount
of needed to satisfy the balance owed at time of application. The monthly rental
amount at the above property is .

✔
Submission of this application does not create a promise of payment of rental
assistance by the Georgia Rental Assistance program. Caseworkers will examine the
file and determine if the full amount requested can be paid under program guidelines.
Landlord can reject participation in the program if the amount payable is unsatisfactory
to the landlord.

✔
Landlord is not requesting assistance for any past due rental amount accrued prior to
March 13, 2020.

Landlord must accept payment from the State of Georgia Rental Assistance Program
via direct/ACH deposit, or via paper check delivered via United States Postal Service
(upon request).

✔
The Unit listed above is not receiving any other form of government or private
assistance for the same months of rent for which this assistance is requested, including
but not limited to tenant-based or project-based vouchers or rental assistance, operating
assistance, Community Development Block Grant, Emergency Solutions Grant, and/or
Housing for Persons with Aids.

✔
If the Unit listed above is receiving any other form of government or private
assistance for the same months of rent for which this assistance is requested, including
but not limited to tenant-based or project-based vouchers or rental assistance, operating
assistance, Community Development Block Grant, Emergency Solutions Grant, and/or
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received (such as Housing Assistance Payment ("HAP") contract). Landlord also
acknowledges that approved rental assistance can only be provided for the tenant-owed
portion of any rental arrearage or eligible future rent payment that is not subsidized.
✔
If the written lease is expired or will expire during period covered by this assistance,
Landlord will enter into a new written lease or extend the current lease with Tenant for a
monthly payment amount no greater than the monthly amount for the expired or expiring
lease or agreement, for a time period at least equal to the period covered by the rent
assistance. The new lease may not increase or impose other fees or charges not
allowed under the current lease with the tenant. The Landlord may continue to charge
all costs, expenses, and fees including but not limited to utility charges if allowed under
the original lease.
✔
Late fees and penalties for nonpayment of rent or any other costs covered by the
rental assistance received by Landlord for the Tenant in this application are allowed up
to 8% of the total rent due. Amounts that exceed the percentage allowed will be waived
upon payment of the rental assistance from the State of Georgia Rental Assistance
Program.

✔
Landlord acknowledges that payment of legal fees is not eligible at this time.

✔
Landlord hereby releases the Tenant and Tenant’s Household from payment liability
for any rent for the time period covered by the assistance actually received by the
Landlord, as well as any fees related to that rent, and will dismiss with prejudice any
pending legal action brought by the Landlord against the Tenant seeking possession of
the property or to collect amounts owed by the Tenant. The Landlord will not evict the
tenant for any reason that predates the acceptance of the funds or for any reason
related to rent or fees during the time period covered by the funds and will not evict the
Tenant for a nonmonetary default during the time period covered by the rental
assistance actually received, except for actions or breaches of the lease that are related
to criminal activity, property damage or physical harm to others. Nothing in this
certification shall waive a Landlord’s right to file an eviction based on a nonmonetary
default that occurs after the expiration of the time period covered by the rental
assistance actually received.

✔
Landlord shall provide the U.S. Department of the Treasury, the U.S. Inspector
General, the U.S. General Accounting Office, the Georgia Department of Community
Affairs, or any of their duly authorized representatives, access to and the right to
examine and copy records related to a payment made as a result of this certification.
Such records will be kept for the longer of seven years, or until after notice of a
monitoring, audit, or litigation, has been provided and the matter has had a final
disposition.
✔
If the Owner is a different legal entity than the Landlord, Landlord or Landlord’s
Agent certifies it has the legal authority to enter into this agreement, and if an Agent is
executing this form, documentation of agency is attached.

✔
Notwithstanding anything to the contrary in this certification, the Landlord shall have
the right to terminate participation in the program at any time prior to receiving
assistance.

✔
The information provided is true, accurate, and complete, and if requested, Landlord
can provide further documentation to support any representations.

In signing this certification (including electronic signature) you are acknowledging that
falsification of documents or any material falsehoods or omissions in the Application,
including knowingly seeking duplicative benefits, is subject to state and federal criminal
penalties. You are particularly put on notice that 18 U.S.C. §1001 provides, among other
things, that whoever knowingly and willingly makes or uses a document or writing
containing any false, fictitious, or fraudulent statement or entry, in any matter within the
jurisdiction of any department or agency of the United States will be fined not more than
$10,000 or imprisoned for not more than five years, or both.

Did anyone assist you in completing this application?

Yes No
If yes, please list their name:
Type/Print your name to sign*:

REQUIRED LANDLORD DOCUMENTS

Please include the following documents with this application and mail it to:

Georgia Dept. of Community Affairs

ATTN: Georgia Rental Assistance Program
60 Executive Park South, NE
Atlanta, GA 30329

Alternatively, you can fax your completed application and supporting documents to
404-393-8829
 ü Proof of Identity*
ü IRS W-9 Form*
ü ACH Direct Deposit Form*
ü MOA/MOU Agreement if property is managed by third-party.

REQUIRED TENANT DOCUMENTS

Please include the following documents with this application and mail it to:

Georgia Dept. of Community Affairs

ATTN: Georgia Rental Assistance Program
60 Executive Park South, NE
Atlanta, GA 30329

Alternatively, you can fax your completed application and supporting documents to
404-393-8829

ü Proof of Ownership*
ü Statement of Delinquent Rent*

Required Documents for Landlords

What documents will a Landlord need to provide to complete the GRA Landlord Application?

Landlords will need the following types of documents/items (e.g., copies, pictures, screenshots,
etc.) along with their signed, fully completed application. The online application will specify the
actual documents required.

Proof of Identity
ü Driver’s license
ü Government-issued photo identification
ü U.S. Military photo ID
ü Tribal photo ID
ü Passport

Proof of Ownership
ü Warranty Deed
ü Tax Record
ü Insurance Binder
 Note: If applicant is a Property Management Company or Legal Representative, applicant
must also attach documentation showing authorization to act on behalf of the property
owner:

ü Authorization Agreement Contract/Memorandum of Understanding (MOU)/Memorandum of

Agreement (MOA)

Financial Documentation
ü IRS W-9 Form
ü ACH Direct Deposit form

Tenant Information
ü Delinquent rent Statement