Proof Of Residency Form printable pdf download

Proof Of Residency Form

Community Coordinated Care for Children, Inc.

Orange County

Osceola County

3500 W. Colonial Drive, Orlando, FL 32808

2220 E Irlo Bronson Mem. Hwy. Unit 7, Kissimmee FL 34744

(407) 522-2252

(321) 219-6300

PROOF OF RESIDENCY FORM

*Note: This form is to be completed by the person with whom the applicant resides

or by the person that holds the lease or rental agreement. The person completing this form

must also provide one of the following: a power bill, gas bill, water bill, mortgage statement,

lease agreement, or rental agreement in their name showing the full residential address.

If providing one of the bills listed above, it must be a bill from within 2 months (60 days) of

the applicant’s interview date.*

To Whom It May Concern:

____________________________________________________

Name of Applicant

Resides at: ___________________________________________

Residential Address

____________________________________________________

City

County

State

Zip Code

Relationship to Applicant:________________________________

Printed Name of Leaseholder:_____________________________

Telephone number of Leaseholder: _________________________

____________________________

______________________

Signature of Leaseholder

Date

Effective 12.19.12

Proof Of Residency Form