New York State Emergency Rental Assistance Program (ERAP)

Office of Temporary and Disability Assistance

Landlord Monthly Rent Confirmation Form
Instructions: Fill in the Summary Table and Monthly Table below for the months being claimed
for ERAP assistance. Note that a given month should only have applicable arrears or
prospective amounts listed – not both.
Summary Table
Tenant Name ANGELA GARROW Total Arrears Owed $ 32000
Address 5072 Tudman rd , westmoreland NY 13490 Total Prospective Amount $

Monthly Table
Regular Monthly Amount Past Due Prospective Rent
Year Month
Rent (Arrears)* Amount**
March $ 2000 $ 2000 $
April $ 2000 $ 2000 $
May $ 2000 $ 2000 $
June $ 2000 $ 2000 $
July $ 2000 $ 2000 $
2020
August $ 2000 $ 2000 $
September $ 2000 $ 2000 $
October $ 2000 $ 2000 $
November $ 2000 $ 2000 $
December $ 2000 $ 2000 $
January $ 2000 $ 2000 $
February $ 2000 $ 2000 $
March $ 2000 $ 2000 $
April $ 2000 $ 2000 $
May $ 2000 $ 2000 $
June $ 2000 $ 2000 $
2021
July $ $ $
August $ $ $
September $ $ $
October $ $ $
November $ $ $
December $ $ $
TOTALS $ $ $
* Late fees are not covered by ERAP. To accept ERAP funds, late fees must be waived and will not be paid.
** Only households who are rent burdened (paying 30% or more of gross monthly income towards rent) may receive
prospective rent payments. Prospective payments are limited to three (3) months.

GABRIEL VELASQUEZ
__________________________________________
Landlord/Property Manager Name (please print)

__________________________________________ 06/03/2021
____________________________
Signature Date
By signing this form, the landlord or property manager attests that the Total Arrears Owed and
Total Prospective Amount listed above are true and accurate for the months, Tenant, and
Address designated above. I also attest that I have not received another payment from another
source for any of the months or amounts requested above.