COVID-19 PANDEMIC IMPACT Checklist

Example Questionnaire: COVID-19 Pandemic Impact Questionnaire

EXAMPLE ONLY -

Preamble: Participants should consider this questionnaire as one of many tools to help homeowners 

identify potential financial hardships associated with the coronavirus pandemic. This questionnaire can 

be a part of identifying potentially eligible households. This questionnaire is not intended as a definitive 

list of eligibility requirements for final determination. HAF Participants should have reasonable policies 

and procedures in place to determine that a homeowner’s hardship is associated with the coronavirus 

pandemic.

Guidance1:

HAF participants must require homeowners to attest that they experienced financial hardship after 

January 21, 2020. The attestation must describe the nature of the financial hardship (for example, job 

loss, reduction in income, or increased costs due to healthcare or the need to care for a family member).

Financial hardship means a material reduction in income or material increase in living expenses 

associated with the coronavirus pandemic that has created or increased a risk of mortgage delinquency, 

mortgage default, foreclosure, loss of utilities or home energy services, or displacement for a 

homeowner.

Sample Questionnaire 

All fields are required.

1. Since January 21, 2020, how has the COVID-19 pandemic negatively affected your household’s 

income or assets?

Check all that apply:

 Wages or hours reduced (including when due to need to care for sick household member or for 

children home from school or daycare) resulting in decreased income

 Currently am or have been unemployed

 Qualified for unemployment benefits

 Laid off or pause in work

 Sick and unable to work

 Loss of child support or spousal support

 Other:__________________

 I did not experience a reduction in income. (This does not automatically disqualify an applicant.)

1 Guidance, page six (as of March 7, 2023)
COVID-19 PANDEMIC IMPACT Checklist

2. Since January 21, 2020, what significant increases in expenses have you had due to the COVID-19 

pandemic?

Check all that apply:

 New or increased healthcare costs

 Remote or at-home work expenses

 Childcare or adult dependent care expenses

 Increased food or food delivery expenses

 At-home care for a household member ill from COVID-19

 Personal Protective Equipment (PPE) including masks

 Air quality (filters, ventilators) expenses

 Alternative transportation expenses due to COVID-19 transportation limitations

 Increased utility bills due to staying at home as a result of COVID-19

 Increased utility or heating costs in light of pandemic- related heating cost increasing

 Other

Other additional expense: _______________________________________________

 I did not experience an increase in expenses due to the pandemic. (This does not automatically 

disqualify an applicant.)

3. Check the boxes that apply to your housing-related financial distress from January 21, 2020 to 

present. Each situation may be a present issue and/or an issue experienced since January 21, 

2020.

 Foreclosure: I am currently in foreclosure on my primary residence.

 Payment: I need assistance to pay my current monthly payment.

 Mortgage Reinstatement: I need financial assistance to reinstate my mortgage related to a 

period of (select all that apply):

o Forbearance

o Delinquency 

o Default

 Insurance: I need financial assistance for (select all that apply):

o Homeowner’s insurance

o Flood insurance 

o Mortgage insurance

 Utilities: I am behind in payments to a utility provider (select all that apply):

o Gas services

o Electric

o Home energy (including firewood and home heating oil)

o Water 

o Wastewater

o Internet access

 Fees and/or Taxes: I need assistance to pay (select all that apply):

o Homeowner’s association fees or liens
COVID-19 PANDEMIC IMPACT Checklist

o Condominium association fees, or common charges

o Costs payable under a unit occupancy agreement by a resident member/shareholder in 

a cooperative housing development

o Delinquent property taxes to prevent tax foreclosure

 Home Repair: I need assistance to prevent displacement due to habitability concerns including 

(select all that apply):

o Repairs for maintaining the home 

o Reasonable addition of habitable space to alleviate overcrowding

 Other Situations I need (select all that apply):

o Payment assistance for a down payment assistance loan provided by a nonprofit or 

government entity

o Payment assistance on a lot rent for a manufactured home

o Mortgage principal reduction, including with respect to a second mortgage provided by 

a nonprofit or government entity

o Mortgage interest rate reduction

o Assistance to enable my household to receive clear title to the property

4. Self-Attestation

 I attest that this information provided for COVID-19 pandemic impact is correct and complete to 

the best of my knowledge.