CDC Tenant's Declaration Form

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Tenant's Declaration Rental assistance in Georgia

Tenant's Declaration

NOTE: The CDC Eviction Moratorium is still in effect. This means you can still use the CDC Tenant Declaration to stop an eviction for nonpayment of rent at this time. (Updated 5/20/21. If this note is here, that means the moratorium is still valid).


Find a PDF version of the CDC Tenant Declaration Form on the CDC website. 




This declaration is for tenants, lessees, or residents of residential properties. Under the CDC’s order you must provide a copy of this declaration to your landlord, owner of the residential property where you live, or other person who has a right to have you evicted or removed from where you live. Each adult listed on the lease, rental agreement, or housing contract should complete this declaration. Unless the CDC order is extended, changed, or ended, the order prevents you from being evicted or removed from where you are living through June 30, 2021. You are still required to pay rent and follow all the other terms of your lease and rules of the place where you live. You may also still be evicted for reasons other than not paying rent or making a housing payment. This declaration is sworn testimony, meaning that you can be prosecuted, go to jail, or pay a fine if you lie, mislead, or omit important information.


  1. Contact any government agency that offers help with rent. Make notes about which organizations you contacted, the date, and what they said.  Keep a copy for your records.

  2. Complete the attached Tenant’s Declaration with the date, your landlord’s contact information, and your contact information.  The Declaration must be signed by each adult on the lease.  Keep a copy for your records. You can find the Tenant's Declaration below or: 

    • The tenant may fill out the certification form electronically and email a copy to the landlord using
      • The tenant should email a copy to any and all email addresses they have for the landlord, property manager, etc
      • If possible, the tenant may want to print a copy of the declaration and give it to the landlord or property manager 
      • The tenant should confirm that page 2 of the declaration contains their signature and personal information before hitting “send”
    • The CDC form can be printed from the CDC website.
  3. Send the Tenant’s Declaration to your landlord by regular mail, certified mail with return receipt requested, and by email.  Keep a copy of any response from your landlord.

  4. Continue to pay as much rent as you can when it is due.  Keep a copy of your receipt.

  5. If your landlord refuses to accept a partial payment, make a record of your attempt to pay and your landlord’s response.

  6. Be prepared to pay all past due rent and fees when the eviction moratorium expires or you may be evicted.

  7. If you are served with an eviction notice please call Atlanta Legal Aid (404-524-5811) or Georgia Legal Services (1-833-457-7529). 

    • You should still file an answer in the case and attend any court hearings.

    • Be sure to include a copy of your Tenant Declaration form with the filings.




DATE: ______________________


TO LANDLORD: _________________________





FROM TENANT(S): _________________________





Re: Tenant’s Declaration under the “Temporary Halt in Residential Evictions” Order


Dear Landlord: 

On September 4, 2020, the Centers for Disease Control and Prevention published an emergency order to temporarily halt residential evictions to stop the spread of COVID-19.  A copy of the Order can be found at and at  The CDC Order is effective from September 4, 2020, through June 30, 2021.  According to the Order, “a landlord, owner of a residential property, or other person with a legal right to pursue eviction or possessory action, shall not evict any covered person from any residential property in any jurisdiction to which this Order applies during the effective period of the Order.”  


The CDC Order contains criminal penalties for violations.  Under 18 U.S.C. 3559, 3571; 42 U.S.C. 271; and 42 CFR 70.18 a landlord may be fined up to $500,000 or jailed.


I certify under penalty of perjury, pursuant to 28 U.S.C. 1746, that the following are true and correct:

  • I have used best efforts to obtain all available government assistance for rent or housing;
  • I either expect to earn no more than $99,000 in annual income for Calendar Year 2020 (or no more than $198,000 if filing a joint tax return), was not required to report any income in 2019 to the U.S. Internal Revenue Service, or received an Economic Impact Payment (stimulus check) pursuant to Section 2201 of the CARES Act;
  • I am unable to pay my full rent or make a full housing payment due to substantial loss of household income, loss of compensable hours of work or wages, lay-offs, or extraordinary out-of-pocket medical expenses;
  • I am using best efforts to make timely partial payments that are as close to the full payment as my circumstances may permit, taking into account other nondiscretionary expenses;
  • If evicted I would likely become homeless, need to move into a homeless shelter, or need to move into a new residence shared by other people who live in close quarters because I have no other available housing options. (“Available housing” means any available, unoccupied residence, or other space in any seasonal or temporary housing, that would not violate occupancy laws and that would not result in an increased housing cost to you.)
  • I understand that I must still pay rent or make a housing payment, and comply with other obligations that I may have under my tenancy, lease agreement, or similar contract. I understand that fees, penalties, or interest for not paying rent or making a housing payment on time as required by my tenancy, lease agreement, or similar contract may still be charged or collected.
  • I understand that at the end of this temporary halt on evictions on June 30, 2021, my housing provider may require payment in full for all payments not made prior to and during the temporary halt and failure to pay may make me subject to eviction pursuant to State and local laws.

I understand that any false or misleading statements or omissions may result in criminal and civil actions for fines, penalties, damages, or imprisonment.


_________________________________      ________________
Signature of Tenant                                         Date


_________________________________      ________________
Signature of Tenant                                         Date

Rental assistance in Georgia




404-363-0575 ext. 242



  • Center for Family Resources: (770) 428-2601  

  • Cobb County Homesaver Program: 

  • Hope Atlanta: (404) 272-2931

  • Must Ministries: (770) 427–9862 

  • Mt. Bethel United Methodist Church: (770) 971-2880

  • Eastside Baptist Church: (770) 971-2323

  • First United Methodist Church: (770) 429-7800

  • Providence Community Baptist Church: (770) 427-3565

  • St. Joseph Catholic Church: (770) 422-5633

  • Salvation Army: (770) 724-1652

  • Star-C:;; 404-698-3781

  • Storehouse Ministries: (770) 428-8410 

  • Turner Chapel AME Church: (770) 422-6791

  • Zion Baptist Church: (770) 427-8749


DEKALB COUNTY (this list does not include all available rental assistance in DeKalb)

  • United Way: 2-1-1

  • DeKalb County Coordinated Entry: 404-687-3500

  • Star-C:;; 404-698-3781

  • Hosea Helps: 404-755-3353

  • Center for Pan Asian Community Services (CPACS): 770-936-0969





  • Georgia Gateway: 

  • Latin American Association: 678-205-1018

  • Salvation Army of Gwinnett County: 770-724-1661

  • St. Vincent de Paul: 678-892-6163

  • United Way: 211

Last Review and Update: Mar 12, 2021