Statement of Delinquent Rent

Tenant Name: __________________________________

Jeffrey Harris

Address of Rental Unit: __________________________

3218 Herrenhut Rd Lithonia, GA
30038
This notice is to inform you that I have not received rent due for the months of:
____ March 2020 (Note: The GRA will not provide assistance for any period prior to March 13,
2020.) (PLEASE DO NOT SELECT ANY FUTURE MONTHS)

____ April 2020 ____ April 2021

____ May 2020 ____ May 2021
____ June 2020 ____ June 2021
____ July 2020 ____ July 2021
____ August 2020 ____ August 2021
____ September 2020 ____ September 2021
____ October2020 ____ October2021
____ November 2020 ____ November 2021
____ December 2020 ____ December 2021
____ January 2021 ____ January 2022
____ February 2021 ____ February 2022
____ March 2021 ____ March 2022

1) The base rent amount not paid for the months checked above is $ _________
21,600

2) Late fees applied to the unpaid rent total $ 1200

_____________
(Note: The GRA program will not pay late fees that exceed 8% of the total past due rent. You will be required to
waive any late fee above the percentage allowed.)

3) Total Amount of past due rent and late fees requested: $_________
22800

I, _____________________(Landlord)
Matthew Fitzpatrick certify that the amounts listed above is what I am owed
for ____________________(Tenant)
Jeffrey Harris ______________________________________
residing at 3218 Herrenhut Rd

______________________________________________
Lithonia, GA 30038
(Street Address, City, State, Zip Code).
I affirm that all the information is true, correct and complete to the best of my knowledge.
In signing this statement (including electronic signature) you are acknowledging that
falsification of documents or any material falsehoods or omissions in the Application, including
knowingly seeking duplicative benefits, is subject to state and federal criminal penalties. You
are particularly put on notice that 18 U.S.C. §1001 provides, among other things, that whoever
knowingly and willingly makes or uses a document or writing containing any false, fictitious, or
fraudulent statement or entry, in any matter within the jurisdiction of any department or
agency of the United States will be fined not more than $10,000 or imprisoned for not more
than five years, or both.
____________________ ______________
02/26/2022
Landlord Signature Date