SELF ATTESTATION FORM

INSTRUCTIONS

This template allows for applicants to self-attest their eligibility for the STAY DC program based on any ONE or MORE of the following

required criteria:

 Rental Obligation (e.g., proof of residence at an eligible rental unit in the absence of a lease/rental/sublease agreement)

 Financial Impact (e.g., unemployment, reduction in income, significantly increased expenses, or other financial hardship)

 Housing Impact (e.g., risk of housing instability or homelessness)

 Income qualification (e.g., total household income at or below 80% AMI)

Carefully read each section and complete ONLY the applicable criteria sections for which you are unable to provide the required 

supporting documentation or a written attestation from an applicable third-party and thus needing to self-attest.

NOTE: This is a fillable form and you can click directly on the boxes within each applicable below to fill in your information directly 

Once you have filled out the applicable criteria sections you must sign the certification at the end.

The completed and signed certification can be printed and attached to your paper application or uploaded with your online application 

at stay.dc.gov

Per guidance from the US Treasury, the STAY DC program may perform additional testing or review processes to help minimize the 

potential for fraud. The use of self-certifications may delay the processing of your application, require additional information from 

you, or result in limitations to the amount of assistance available to you.

If you have any questions about the documentation requirements, visit the program website at stay.dc.gov or feel welcome to call the 

Contact Center at 833-4-STAYDC (833-478-2932) between 7am and 7pm ET, Monday through Friday.
SELF-ATTESTATION OF RENTAL OBLIGATION

IF you cannot provide the required documentation of rental obligation at this time, please provide information about your rental housing 

using this form. [IF you have this documentation and plan to provide it as part of your application, you can skip to the next section of the form.]

Please provide information about your rental unit and housing provider

Rental Unit Address

Address 2

City

State

Zip Code

Name of Housing Provider

Housing Provider Email 

Address

Housing Provider Phone 

Number

Date Rental Arrangement 

Began (optional)

Date Rental Agreement is 

Scheduled to end (optional)

Does Monthly Rent Include Utilities?  Yes  No

If yes, how much of monthly payments to housing provider is related to utilities?

Note: if you are using a written attestation to demonstrate your current rental obligation, assistance provided to you under the STAY DC 

program will be limited to a monthly maximum of 100% of the greater of the Fair Market Rent or the Small Area Fair Market Rent for the 

area in which the applicant resides, as most recently determined by HUD and made available at 

https://www.huduser.gov/portal/datasets/fmr.html.

Further, assistance provided based on written self-attestation of the rental payment amount is limited to three (3) months total.
SELF-ATTESTATION OF FINANCIAL IMPACT QUALIFICATION

IF you cannot provide the required documentation of financial impact at this time, please explain how you or one or more individuals within 

the household has qualified for unemployment benefits or experienced a reduction in household income, incurred significant costs, or 

experienced other financial hardship due, directly or indirectly, to the COVID-19 outbreak. [IF you have the required documentation and plan 

to include it with your application, you can skip to the next section of the form.]
SELF-ATTESTATION OF RISK OF HOUSING INSTABILITY OR HOMELESSNESS

IF you cannot provide the required documentation of risk of housing instability or homelessness at this time, please explain how you or one 

or more individuals within the household is at risk of housing instability or homelessness. [IF you have the required documentation and plan 

to include it with your application, you can skip to the next section of the form.]

Please explain how you or one or more individuals within the household is currently at risk of experiencing homelessness or housing

instability (this is demonstrable through past due utility or rent notice or eviction notice or unsafe or unhealthy living conditions)
SELF-ATTESTATION FOR HOUSEHOLD INCOME QUALIFICATION

IF you cannot provide the required documentation of income at this time, or you believe your income is categorically eligible as described 

below, please use this form to document your income. [IF you have the required documentation and plan to provide it as part of your 

application, you can skip to the signature page.]

Categorical Eligibility

Please indicate if your household income has been certified as eligible on or after January 1, 2020 due to your enrollment in ONE or more of 

the following District or Federal programs:

 Tenant-based Housing Choice Voucher

 Project-based Housing Choice Voucher

 Public Housing

 Low Income Housing Tax Credit

 DC Housing Production Trust Fund

 National Housing Trust Fund

 Home Investment Partnerships (HOME)

 Inclusionary Zoning

 Veterans Affairs Supportive Housing (VASH) Voucher

 Rapid Rehousing

 Project Based HCV COVID-19 Housing Assistance Program (CHAP)

 Tenant-Based Rental Assistant (TBRA)

 Housing Stabilization Grant (HSG)

 DC Emergency Rental Assistance Program (Local)

 Supplemental Nutrition Assistance Program (SNAP)

 Temporary Assistance for Needy Families (TANF)
Household Income Attestation

IF you cannot provide the required documentation and do NOT qualify for any of the above programs at this time, please use this form to

document your income. [IF you have the required documentation and plan to provide it as part of your application, you can skip to the

signature page.] 

Note that self-attestation of household income will require that you re-certify income every three months in order to receive future funding. 

FULL NAME (including YOURS) 

RELATIONSHIP TO 

YOU (Indicate 

“self” for your 

name)

EMPLOYED?

(Y or N)

Annual GROSS 

INCOME

Annual gross income from all sources (total of all members)

Household income is determined using one of the two following methods: 

 2020 ANNUAL INCOME: Sum of all your rental household members’ income for calendar year 2020 using the Adjusted Gross Income

(AGI) as noted on your Internal Revenue Service (IRS) Form 1040 series for individual Federal annual income tax purposes; or

 RECENT ANNUAL INCOME: Sum of all your household members’ income in the last two months and multiplied by 6. If this method is

used to determine income eligibility, applicants will need to recertify their income every 3 months for any award extensions applied for

by the applicant.

Potential sources of income may include: salary, wage, tips, commissions, business income, interest, dividend, social security benefit, annuities, 

insurance, Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits, unemployment and disability 

compensation, worker's compensation and severance pay, and Welfare assistance payments.
Attestation of lack of income documentation

Please detail the circumstances that do not permit you to provide the required supporting documents necessary to complete an income 

eligibility review: 
CERTIFICATION

I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct.

I agree to provide, upon request, additional information or documentation upon request to the STAY DC Program Administrator.

Applicant Signature: _________________________________________

Date: _________________________________________

WARNING: The information provided on this form is subject to verification by the Treasury Department at any time, and Title 18,

Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and

willingly making a false or fraudulent statement to a department of the United States Government.