INSTRUCTIONS

TENANT’S SELF-CERTIFICATION OF LEASE

1. USE THIS FORM ONLY IF THERE IS NO WRITTEN LEASE AND THE LAND LORDLORD WILL NOT 

SIGN A CERTIFICATION OF LANDLORD/TENANT RELATIONSHIP – The Tenant Self-Certification of 

Lease should be used only if a formal, written lease does not exist and the Landlord cannot or 

will not sign the Certification of Landlord/Tenant Relationship.

2. DO NOT MAIL THIS FORM TO THE MRAP PROGRAM – Applicants applying for assistance under 

the MRAP should upload this form in lieu of a written lease or the Landlord/Tenant Relationship 

form when completing their on-line application.

3. INCLUDE ALL REQUIRED ATTACHMENTS – The self-certification requires certain documents be 

included with the certificate. These items should also be uploaded with the form when tenant 

completes their on-line application. See certificate for list of required documents. 

4. COMPLETE ALL FIELDS AND QUESTIONS ON THE CERTIFICATE

5. SIGN THE CERTIFICATE – The certificate must be signed by the tenant head of household. 

FAILURE TO PROPERLY COMPLETE THE CERTIFICATE AND SUPPLY THE REQUIRED ATTACHEMENTS 

WILL CAUSE A DELAY PROCESSING APPLICATIONS FOR ASSISTANCE UNDER THE MRAP
EXHIBIT A-2 – TENANT’S SELF-CERTIFICATION OF LEASE

(To be Submitted by Head of Household only if no written lease is available and Landlord cannot or 

will not sign Exhibit A-1 Certification of Landlord/Tenant Relationship) 

Head of Household’s Name: ______________________________________________________________

Head of Household’s Spouse (if applicable): _________________________________________________

Other Household Members 18 & Over: _____________________________________________________

Landlord’s Name (name where rent is sent): _______________________________________________

Landlord’s Address: ____________________________________________________________________

Landlord’s Phone Number: ____________________________________

Landlord’s Email Address: _____________________________________

Rental Property Address: __________________________________________________ (the “Property”)

How long have you rented the Property? _________________________

Term of Lease:__________ Expiration of Lease:__________ Monthly Rent Payment:____________

Are any utilities included in your rent payment? ☐ Yes ☐No If yes, list which utilities are included: 

____________________________________________________________________________.

Are you behind in rent: ☐ Yes ☐ No If yes, how much rent is past due $_____________?

Applicant must attach the following to this Certification:

1. Evidence of Rent payments (may include bank statements, cleared or cancelled checks, or other 

documentation that reasonably evidences a pattern of paying rent) (i) paid by tenant to the 

Landlord listed in the application; and (ii) for a period of 3 or more months since January 1, 

2020.

And 

2. Evidence Utility Payments (may include bank statements, cleared or cancelled checks, or other 

documentation that reasonably evidences a pattern of paying utilities) (i) paid at the address 

listed on the application, (ii) for a period of 3 or more months since January 1, 2020; (iii) utility 

invoice must be dated within thirty days of the application date; and (iv) fully completed 

Tenant’s Certification of Lease. 

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 MRAP Program and other remedies available under applicable law. 

___________________________ ____________________________ ___________________

Signature of Head of Household Printed Name of Head of Household Date