Application Tenant Rental&UtilityAssistance 40403

Program Overview Case Id: 40403
Name: Clack,Taira - 2021

Completed by clacktaira@gmail.com on 12/9/2021 10:07 AM
Address: 7109 BROOMFIELD WAY
Program Overview
Please provide the following information.
HOUSE WAKE!
COVID-19 FINANCIAL ASSISTANCE PROGRAM
Tenant Application
Telamon Corporation
5560 Munford Rd., Suite 109
Raleigh, NC 27612
(919) 899-9911
housing@telamon.org
The House Wake! COVID-19 Financial Assistance Program focuses specifically on eviction prevention and utility
assistance. This program provides financial assistance to tenants, landlords and utility companies to cover rent and
utility shortfalls resulting from a financial hardship directly or indirectly due to COVID-19. Qualifying households
must have income that does not exceed 80% area median income with priority given to households with incomes
below 50% AMI. , If you have questions regarding this application or need assistance, please call Telamon at (919)
899-9911.
NOTE: Much of the correspondence for this Program is via EMAIL, so please check your Spam email folder if you
have not received any emails from Neighborly Software or from housing@telamon.org .
Printed By: T'aira Clack on 12/11/2021 1 of 25
Eligibility criteria for BOTH Tenant AND Landlord are outlined in the two sets of criteria below. Before proceeding, it is
recommended that both parties discuss and agree that they are both willing and able to proceed and that both will
complete the online application, provide all required items, and abide by all required terms.
If you’ve been issued an eviction notice, contact Legal Aid of North Carolina immediately at 1-866-219-5262
Eligibility Criteria for Tenant:
1. Must be a Wake County resident, with proof of residency, and residing in the property that is in arrears as
primary residence and;
2. One or more adults in the household must have qualified for unemployment benefits or has experienced a
reduction in household income, incurred significant costs, or experienced other financial hardship due directly
to the coronavirus outbreak that can be documented and;
3. One or more adults in the household must be able to demonstrate a risk of experiencing homelessness or
housing instability such as a past due rent or utility notice, pay rent or quit notice, court issued eviction notice,
or documented inability to pay prospective rent and;
4. Must be able to provide a fully executed rental lease or agreement where the lease is in the Applicant’s name
and the Applicant is responsible for monthly rent payments and;
5. Household income must fall at or below these brackets:
Household
1 2 3 4 5 6 7 8
Size
Income $53,600.00 $61,250.00 $68,900.00 $76,550.00 $82,700.00 $88,800.00 $94,950.00 $101,050.00
6. Must read and agree to full Terms & Conditions that are outlined prior to submission of the application.
Eligibility Criteria for Landlord:
1. Must provide a valid W-9 for payment to the owner of the rental property .
2. Must confirm that any rental arrears submitted for consideration are for Wake County property(ies) only.
3. Must read and agree to full Terms & Conditions that are outlined prior to submission of the application.
Please review thoroughly prior to submitting application.

A. Eligibility Case Id: 40403
A. Eligibility
The following questions will help determine whether your household meets basic eligibility for the HOUSE WAKE! COVID-19
FINANCIAL ASSISTANCE PROGRAM.
A.1. Is your household income at or below the 80% area median income level?
No
Household
1 2 3 4 5 6 7 8
Size
Income $53,600.00 $61,250.00 $68,900.00 $76,550.00 $82,700.00 $88,800.00 $94,950.00 $101,050.00
A.2. Are you delinquent on your rent and/or utility payments or know you won’t be able to pay next month’s rent?
Yes
A.3. Are you a resident of Wake County?

Yes
A.4. Have you qualified for unemployment benefits OR Do you have proof that you have experienced a reduction in
household income, incurred significant costs, or experienced other financial hardship due directly to the
coronavirus outbreak that can be documented?
Yes
IF YOU ANSWERED NO TO ANY OF THESE QUESTIONS, YOU MAY NOT BE ELIGIBLE FOR
EMERGENCY RENTAL ASSISTANCE. YOU CAN CONTINUE THE APPLICATION, AND WE WILL
NOTIFY YOU OF YOUR ELIGIBILITY BASED ON YOUR COMPLETED APPLICATION.

B. Applicant Information Case Id: 40403
B. Applicant Information
PRIMARY APPLICANT
B.1. Applicant First Name:
Taira
B.2. Applicant Last Name

Clack
B.3. Home Address

7109 BROOMFIELD WAY RALEIGH, NC 27615
B.4. Telephone Number

(919) 559-8012
B.5. E-Mail
clacktaira@gmail.com
B.6. How did you hear about the program?

Landlord/Property Manager
B.7. Is any household member currently receiving

unemployment compensation for at least 90 days?
No
B.8. Are you disabled?

No
B.9. Are you a veteran?

No
B.10. Number of Bedrooms In Unit

2

C. Household Members Case Id: 40403
C. Household Members
List all household members.
Name: Taira Clack

Birthdate: 11/28/1999
Employer: Not employed Demographics: Relationship to Head of
Household: Self
Race: Black/African American
& White
Ethnicity: Non-Hispanic or
Latino
Gender: Female
Veteran Status: I am not
Veteran
Disabled: I am not Disabled
Total Household Members: 1

D. Income Verification Case Id: 40403
Household Income Verification
You have three options for reporting/entering your household income. The three options are outlined below and you can select one
of the options and follow the instructions for that option. Household income is income earned by everyone within the household
over the age of 18.
Option 1: Enter the "adjusted gross income" from your 2020 tax return filed with the IRS. The tax return must be signed and the first
two pages must be uploaded.
OR
Option 2: : Medicaid, Women, Infants, and Children (WIC) benefits Supplemental Nutrition Assistance Program (SNAP), Food
Distribution Program on Indian Reservations (FDPIR), Temporary Assistance for Needy Families (TANF), , Subsidized housing (not
including housing choice, project based, or Section 8 vouchers) that required income documentation as a condition of residency, Any
household income-based state or federally funded assistance program for low-income persons or households, Any locally operated
assistance program for low-income persons or households that requires household income verification and uses federal income
limits. Any paperwork uploaded must show the name of the person receiving the benefit, the address of the person receiving the
benefit, and must have been issued after January 1, 2020.
OR
Option 3: Enter income information for every household member reporting income for each applicable type of income following the
instructions below. Note: You will need to upload supporting documents for each type of income reported.
Follow the instructions below to add all sources of income for each household member reporting income. If a household member
has zero income, then a "Certification of Zero Income Form" will be available for download. Complete this form and upload it as
Certification of Zero Income. .
To add an income source:

1.Click the plus sign (+) to expand the menu.
2. Click the button that shows up titled "Add Source of Income."
3. Select the appropriate source of income using the drop down box for each income source. If other is selected, a written
description is required in the "Additional Information" box.
4. Enter the expected income for the next 12 months specific to the source. The blue calculator (next to the income amount) can
convert partial year income, hourly income and monthly income into an annual amount.
5. Upload the appropriate documentation as prompted.
6.Repeat for each source of income for each household member until ALL household income is entered.
Failure to include ALL income information for every household member may prevent assistance from being provided OR you may be
required to REPAY assistance if you are found to be ineligible after assistance is granted.
 2020 Tax Return *Required

**No files uploaded
◦I will certify my household annual income by using my 2020 Federal Income Tax Return (upload required)
◦My household qualifies based on our participation in another income-based state or federally funded assistance program.

•I will certify my annual household income by documenting each household members income source(s).
1 Taira Clack Total $0.00
Age: 22
Household Income Summary
Income Limits Used 2021 HUD Total Household Income (Monthly) $0.00
Income Limits Total Household Income (Annual) $0.00
# of Household Members 1 Asset Interest Income (Annual) $0.00
Approval Threshold 80.00 % Total Combined Income (Annual) $0.00
AMI @ Threshold $53,600.00 Percent of AMI 0.00 %
AMI Table
AMI = Area Median Income

Household 1 people 2 people 3 people 4 people 5 people 6 people 7 people 8 people
Size
AMI 100% $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
AMI 80% $53,600.00 $61,250.00 $68,900.00 $76,550.00 $82,700.00 $88,800.00 $94,950.00 $101,050.00
Staff Certification Applicant Signature
Co-Applicant Signature

E. COVID-19 Impact Case Id: 40403
E. COVID-19 Impact
E.1. Has the leaseholder or other members of the leaseholder household lost income due to the COVID-19 pandemic?
Yes
E.2. Please check each condition that applies to the leaseholder or other members of leaseholder household who
have lost income due to the COVID-19 pandemic (check all that apply):
 Have been laid off temporarily or permanently
 Have had work hours reduced
 Were about to start a new job but could not, or were terminated from a new job before establishing sufficient
work history to be eligible for regular benefits.
 Are self-employed, and their business is no longer supplying them with income or such income has been
reduced.
 Are independent contractors or gig workers who have not been able to earn fees, or whose fees have been
reduced.
 Have become sick themselves or have been advised by a governmental or medical professional to self
quarantine.
 Have had to leave a job or reduce hours in order to care for a person who is sick.
 Have had to leave a job or reduce hours to care for dependents whose ordinary situations (such as school or
daycare) have been disrupted.
 Have reasonable concern over the risk of infection at work, for themselves or someone in their household.
(Examples include individuals who themselves or live with someone who is elderly, have underlying conditions that
render them more vulnerable, or are immunocompromised).
 I had an unexpected COVID related medical of funeral expense
 I am living in a car, outside, or other place not meant for human habitation
 Have other conditions resulting in loss of income due to the COVID-19 pandemic. (Please describe below.)
If you selected "Other," please describe the situation below.
I recently just got over covid for the second time this year
E.3. Please provide a short description of your COVID-19 Income Loss

I lost my job due to covid cut backs , tried to get another job and caught covid19. have been out of work for almost 2
months now
Supporting documentation
 Please upload COVID-19 Loss of income documentation such as letter from employer, description of loss of self-
employment income, letter showing reduction in hours *Required
Termination Letter Taira Clack.pdf

F. Rent Assistance Requested Case Id: 40403
G. Assistance Request
Fill out the amount that you are requesting for each month of housing payments that you require assistance for due to your
household’s COVID-19 impact. For instance, if you require assistance for $1,000 of rent missed in November 2020, but only $500 of
rent missed in December 2020, then you would fill out $1,000 in November 2020 and $500 in December 2020.
RENTAL ASSISTANCE REQUESTED LANDLORD INFORMATION

F.1. Are you requesting rent Assistance? F.6. Property Name/Name of Apartments
Yes The Parks at North Ridge
F.2. Have you received a notice to vacate from your F.7. Landlord Phone Number
landlord or property management? (919) 878-8585
Yes
F.8. Landlord Email
If yes, please upload vacate notice theparkatnorthridge@bellpartnersinc.com
 Vacate Notice *Required
F.9. Name of Property Manager/Landlord
IMG_3861.jpg Lauren
F.10. Landlord/Property Management Address

F.3. Have you received an eviction notice from your 7100 Claxton Circle Raleigh, NC 27615
landlord, and/or a summons, complaint, or judgment for
eviction issued by the court?
No
F.4. What is your current monthly rent?

$1,412.00
F.5. Rent request by month.
March 2020
$0.00
April 2020
$0.00
May 2020
$0.00
June 2020
$0.00
July 2020
$0.00
August 2020
$0.00
September 2020
$0.00
October 2020
$0.00
November 2020
$0.00
December 2020
$0.00
January 2021
$0.00
February 2021
$0.00
March 2021
$0.00
April 2021
$0.00
May 2021
$0.00
June 2021
$0.00
July 2021
$0.00
August 2021
$0.00
September 2021
$0.00

October 2021
$1,412.00
November 2021
$1,412.00
December 2021
$2,410.30
January 2022
$0.00
February 2022
$0.00
March 2022
$0.00
April 2022
$0.00
May 2022
$0.00
June 2022
$0.00
July 2022
$0.00
August 2022
$0.00
September 2022
$0.00
October 2022
$0.00
November 2022
$0.00
December 2022
$0.00

G. Utility Assistance Requested Case Id: 40403
G. Utility Assistance
WATER/SEWER ASSISTANCE GAS/PROPANE ASSISTANCE ELECTRIC ASSISTANCE REQUESTED

REQUESTED REQUESTED G.13. Is this utility included in your
G.1. Is this utility included in your G.7. Is this utility included in your lease?
lease? lease? No
Yes No
G.14. Are you requesting electric
If you answered yes to the above G.8. Are you requesting gas/propane utility assistance?
please select No below for this type utility assistance? Yes
of utility assistance. No
G.15. Electric Company Name
G.2. Are you requesting water/sewer Duke Energy (Carolinas)
utility assistance?
No If other utility provider, list name
G.16. Electric Account Number

7336486530
G.17. Electric Assistance Request
March 2020
$0.00
April 2020
$0.00
May 2020
$0.00
June 2020
$0.00
July 2020
$0.00
August 2020
$0.00
September 2020
$0.00
October 2020
$0.00
November 2020
$0.00
December 2020
$0.00
January 2021
$0.00
February 2021
$0.00
March 2021
$0.00
April 2021
$0.00
May 2021
$0.00
June 2021
$0.00
July 2021
$0.00
August 2021
$0.00
September 2021
$0.00
October 2021
$0.00
November 2021
$0.00
December 2021
$359.34
January 2022
$0.00
February 2022
$0.00
March 2022
$0.00
April 2022
$0.00
May 2022
$0.00
June 2022
$0.00
July 2022
$0.00
August 2022
$0.00
September 2022
$0.00
October 2022
$0.00
November 2022
$0.00
December 2022
$0.00
Total Electric Request

$359.34
G.18. If you are requesting electric

assistance, you must upload your
most recent electric utility statement.
 Electric Utility Statement
*Required

IMG_3863.jpg

H. Internet Assistance Requested Case Id: 40403
H. Internet Service Assistance Request
INTERNET SERVICE ASSISTANCE REQUESTED

H.1. Is this utility included in your lease?
No
H.2. Are you requesting internet utility assistance?

No

I. Prior Assistance Received Case Id: 40403
I. Prior Assistance Received
Assistance provided under the Emergency Rental Assistance Program for households economically impacted by COVID-19 may not
exceed a household's monthly unmet housing cost needs. List all other sources of rent or utility assistance received from local
governments, the State, Owner Preservation Program, non-profit organizations, faith based organizations, or friends and family.
PRIOR HOUSING ASSISTANCE RECEIVED

I.1. Has anyone in your household applied for, or received any rental and/or utility assistance from any source (local,
state, federal, private) FOR THE MONTHS YOU ARE APPLYING TO HOUSE WAKE FOR? If yes, proceed with this section.
If no, mark this section "Complete and Continue" and proceed to the next section.
No
I.2. List the housing assistance that you have already received each month, where applicable. List all of the sources of
financial and/or housing assistance (the name of the local, state, federal or private organization) FOR ONLY THE
MONTHS YOU ARE APPLYING TO HOUSE WAKE
March 2020
$0.00
March Assistance Source
April 2020
$0.00
April Assistance Source
May 2020
$0.00
May Assistance Source
June 2020
$0.00
June Assistance Source
July 2020

$0.00
July Assistance Source
August 2020
$0.00
August Assistance Source
September 2020
$0.00
September Assistance Source
October 2020
$0.00
October Assistance Source
November 2020
$0.00
November Assistance Source
December 2020
$0.00
December Assistance Source
January 2021
$0.00
January Assistance Source
February 2021
$0.00
February Assistance Source

March 2021
$0.00
April 2021
$0.00
May 2021
$0.00
June 2021
$0.00
July 2021
$0.00
August 2021
$0.00
September 2021
$0.00
October 2021
$0.00

November 2021
$0.00
December 2021
$0.00
January 2022
$0.00
January Assistance Source
February 2022
$0.00
February Assistance Source
March 2022
$0.00
April 2022
$0.00
May 2022
$0.00
June 2022
$0.00

July 2022
$0.00
August 2022
$0.00
September 2022
$0.00
October 2022
$0.00
November 2022
$0.00
December 2022
$0.00
I.3. Upload Document(s) About Housing Assistance

 Award Letters/Checks for Housing Assistance
**No files uploaded

J. Required Documents Case Id: 40403
J. Required Documents
Documentation
 Utility bill with the lease address in name of applicant (If Photo Id does not match address)
IMG_3863.jpg
 Valid Photo ID for all adult household members (18 years of age or older) *Required
IMG-3151 (1).jpg
 Most Recent Rent Statement (Must show name, address, and rental amount due)
IMG_3861.jpg
 Rental Agreement / Documentation that Shows Rental Arrangement *Required

residentattachmentview.ashx.pdf

Submit Case Id: 40403
Submit
Once an application is submitted, it can only be "Re-opened" by an Administrator. Also note: please check your Spam email folder
if you have not received any emails from Neighborly.
 Release of Information
I understand that validating information contained in this application will require program staff to contact my
landlord. I give my permission for the landlord and program staff to exchange information to validate active lease,
rental payments, rent owed and facilitate enrollment as a vendor. Furthermore, I give my permission for program
staff to communicate with employers or other originators of documents I have provided to establish my eligibility.
Information exchanged will be used to determine program qualification and enrollment. I do hereby indemnify and
forever hold harmless the landlord, from all actions and causes of actions, suits, claims, attorney fees, or demands
against the landlord which I and my heirs may have resulting from the landlord’s discussing my account and/or
providing any information concerning the rental account to Telamon Corporation housing staff.
 Privacy Policy
Telamon is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We
realize that the concerns you bring to us are highly personal in nature. We assure you that all information shared both
orally and in writing will be managed within legal and ethical considerations. Your information may be provided to
funders for program monitoring purposes. We may use anonymous aggregated case file information for reporting on
and evaluating our services, gathering valuable research information, and designing future programs. Release of your
information to third parties:
1. We may disclose some or all of the information that we collect to third parties as a requirement of grant awards
which make our services possible.
2. We may also disclose any nonpublic personal information about you or former customers to anyone as permitted
by law (e.g., if we are compelled by legal process).
3. Within the organization, we restrict access to nonpublic personal information about you to those employees who
need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards
that comply with federal regulation to guard your nonpublic personal information. Submission of this application
indicates I have reviewed and understand the above Privacy Policy.
 Complaint Resolution Process Telamon serves all members of the community. We do not engage in the practice
of discrimination in the selection and participation of clients in our programs or services with respect to race, religion,
age, color, gender, national origin, or disability. We are committed to providing you with a high-quality professional
service. However, if you are not satisfied with the services provided or you want to make a complaint, we ask that
you follow these guidelines: Step One: Try to resolve the issue with the staff member involved, giving him or her
specific information about your complaint. Step Two: If Step One is not possible or the issue is not resolved to your
satisfaction, email, write or call the Housing Director at 919-239-8157 or at housing@telamon.org. Step Three: If your
issue is still unresolved, you may appeal in writing directly to the Chief Executive Officer of Telamon Corporation. The

Chief Executive Officer will provide a concluding decision to you within 15 days. Step Four: If your issue is still
unresolved, you may appeal in writing directly to the Telamon Governing Board Operations Committee. The
Committee Chair will provide a concluding decision to you within 15 days.
 Completed Application Certification I understand that it is against the law for me to make false statements and
that I am subject to prosecution if I do. I further understand that if any false statements are made in connection with
this application, Telamon Corporation may seek any remedies available under law, including monetary relief in the
form or repayment and reimbursement of all benefits received and/or costs attributed to the collection thereof. I
certify that the information I have provided is a true and complete statement of facts according to the best
knowledge and belief. I give the agency permission to verify any information necessary to determine my eligibility for
the - House Wake! COVID-19 Financial Assistance Program. I understand that the information on this form may be
checked by the Federal, State, County or City reviewer and I consent to this review. Furthermore, I understand that
my application must be complete and include all necessary supporting documentation to be considered for the -
House Wake! COVID-19 Financial Assistance Program. I agree to provide additional documentation within designated
timelines to the Program Administrator if necessary.
 I further grant permission and authorize any bank, employer, or other public or private agency to disclose
information deemed necessary to complete this application.
Authorized Signature
Taira Clack
Electronically signed by clacktaira@gmail.com on 12/9/2021 10:45 AM

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Program Overview Case Id: 40403

Name: Clack,Taira - 2021

Please provide the following information.

Eligibility Criteria for Tenant:

Eligibility Criteria for Landlord:

Printed By: T'aira Clack on 12/11/2021 2 of 25

A.3. Are you a resident of Wake County?

Printed By: T'aira Clack on 12/11/2021 3 of 25

Please provide the following information.

B.2. Applicant Last Name

B.3. Home Address

B.4. Telephone Number

B.6. How did you hear about the program?

B.7. Is any household member currently receiving

B.8. Are you disabled?

B.9. Are you a veteran?

B.10. Number of Bedrooms In Unit

Printed By: T'aira Clack on 12/11/2021 4 of 25

List all household members.

Name: Taira Clack

Total Household Members: 1

Printed By: T'aira Clack on 12/11/2021 5 of 25

Household Income Verification

To add an income source:

 2020 Tax Return *Required

Printed By: T'aira Clack on 12/11/2021 6 of 25

Household Income Summary

AMI = Area Median Income

Staff Certification Applicant Signature

Printed By: T'aira Clack on 12/11/2021 7 of 25

 Have been laid off temporarily or permanently

 Have had work hours reduced

E.3. Please provide a short description of your COVID-19 Income Loss

Printed By: T'aira Clack on 12/11/2021 8 of 25

Printed By: T'aira Clack on 12/11/2021 9 of 25

RENTAL ASSISTANCE REQUESTED LANDLORD INFORMATION

F.10. Landlord/Property Management Address

F.4. What is your current monthly rent?

F.5. Rent request by month.

Printed By: T'aira Clack on 12/11/2021 11 of 25

Printed By: T'aira Clack on 12/11/2021 12 of 25

Please provide the following information.

WATER/SEWER ASSISTANCE GAS/PROPANE ASSISTANCE ELECTRIC ASSISTANCE REQUESTED

G.16. Electric Account Number

G.17. Electric Assistance Request

Total Electric Request

G.18. If you are requesting electric

Printed By: T'aira Clack on 12/11/2021 15 of 25

Printed By: T'aira Clack on 12/11/2021 16 of 25

H. Internet Service Assistance Request

Please provide the following information.

INTERNET SERVICE ASSISTANCE REQUESTED

H.2. Are you requesting internet utility assistance?

Printed By: T'aira Clack on 12/11/2021 17 of 25

I. Prior Assistance Received

PRIOR HOUSING ASSISTANCE RECEIVED

March Assistance Source

April Assistance Source

May Assistance Source

June Assistance Source

Printed By: T'aira Clack on 12/11/2021 18 of 25

July Assistance Source

August Assistance Source

Application Tenant Rental&UtilityAssistance 40403

Application Tenant Rental&UtilityAssistance 40403