Ocean County COVID-19 Impact and Risk of Homelessness Attestation

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IMPORTANT INFORMATION

Please complete this form to the best of your ability. One form is required per household.

Households must demonstrate a negative economic impact from the pandemic, such as unemployment, increased food or housing instability, or low- to moderate-income, in order to receive certain services supported by Ocean County's Coronavirus State and Local Fiscal Recovery Funds plan.

Inquiries about this form can be addressed to oceandhs@co.ocean.nj.us. Any other questions should be directed to your service provider.

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Agency Providing Services

How has the COVID-19 pandemic (since March 2020) affected your household's income or assets? Check all that apply.

Currently am or have been unemployed

Qualified for Unemployment benefits

Laid off or pause in work

Medically at-risk and unable to work

Caring for COVID-impacted household member

Loss of child or spousal support

Caring for children at home due to remote education or closed daycare

I/we did not experience a reduction in income

I attest that this information provided for COVID-19 pandemic impact is correct and complete to the best of my knowledge.

I attest that this information provided is correct and complete to the best of my knowledge.

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Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in the repayment of any funds received through the Ocean County Residential Emergency Rental Assistance Program and other remedies available under applicable law.