OMB Control No.
1920-1303
Form Expiration: 2/28/2022
Eviction Protection Declaration
The Centers for Disease Control and Prevention (CDC) has issued an order that may protect you from being evicted or
removed from where you are living. This means that you may be able to stay at the place where you live through
October 3, 2021, if you qualify.
How to use this form
1. See if you qualify for eviction protection under the CDC order. If you’d like help from an expert, contact the US De-
partment of Housing and Urban Development (HUD) at (800) 569-4287 or go to https://www.hudexchange.info/pro-
grams/housing-counseling/rental-eviction/ to get contact information for a local housing counselor.
2. Sign the declaration that you qualify, on the next page.
3. Give the signed declaration page to the individual or company you rent from (for example, building management,
landlord, etc.). Keep a picture or copy for your records and call your expert back if there’s a problem.
If your landlord violates the CDC order, they could be subject to criminal penalties, including fines or a term of imprisonment.
1. Do I qualify?
If you can check at least one box in each column, you qualify.
Column A AND Column B
I received a stimulus check (Economic Impact I cannot pay my full rent or make a full housing
Payment) in 2020 or 2021 payment because:
I was not required to report any income to the My household income has gone
IRS in 2020 down substantially
I am receiving any of the following benefits: I have been laid off from work
• Supplemental Nutrition Assistance Program My work hours or wages have been cut
(SNAP)
I have extraordinary out-of-pocket
• Temporary Assistance for Needy Families medical expenses1
(TANF)
• Supplemental Security Income (SSI) None of the above — You do not qualify.
• Supplemental Security Disability Income
(SSDI)
In 2020 or 2021, I earned (or expect to earn)
less than $99,000 as an individual or less than
$198,000 as a joint filer
None of the above — You do not qualify.
You checked at least one item in each column? Your income level qualifies.
[Check the first box on the next page]
Defined as 7.5% or more of my adjusted gross income for the year
1
CS326004_A 08/04/2021
2. My Declaration that I qualify
Troubleshooting
By checking the boxes below, I declare that each statement is true. tools for tenants
My income level qualifies for the reasons explained above. Find emergency rental
I live in a U.S. county experiencing substantial or high rates of community
2 financial assistance
transmission levels of SARS-CoV-2. Call (800) 569-4287 to
find a listing for local
I have done my best to make timely partial payments that are as close as
HUD-approved housing
possible to the full payment and to get government assistance in making
counselors
my rent or housing payments.3
If I were evicted, I have no other available housing options, so I would: Report problems with
• Probably become homeless, or debt collection
• Have to move to a homeless shelter, or Submit a complaint to CFPB
cfpb.gov/complaint
• Have to move in with others who live in close quarters.
I understand that after I sign: Report discrimination
• Unless I come to an agreement with my landlord, I am still responsible Submit a complaint.
for rent, back rent, and any fees, penalties or interest under my lease. Call HUD at (800) 669-9777
• I must still follow the conditions of my lease.
• Unless I come to an agreement with my landlord, if I fail to make my
required payments, I could be evicted when this temporary halt of
evictions ends.
• I can still be evicted for reasons other than not paying rent or not making
a housing payment.
I sign this declaration4 under penalty of perjury. That means I promise that the statements
above are the truth and that I understand that I can be criminally punished for lying.
You sign here:
Date:
3. Give this signed page to the individual or company you rent from.
ATTN LANDLORDS: Thank you for your compliance. If you violate the CDC’s Eviction Order, you and/
or your business may be subject to criminal penalties, including fines and a term of imprisonment.
2
See COVID-19 Integrated County View: https://covid.cdc.gov/covid-data-tracker/#county-view/
3
Calling a local expert is the best way to figure out all the help that is available to you. Find a listing for a local HUD-approved housing counselor by calling
(800) 569-4287.
4
If you have already signed an eviction moratorium declaration, you do not need to submit another one.
