Utility Account Certification Form printable pdf download

GASTONIA HOUSING AUTHORITY

SECTION 8

UTILITY ACCOUNT CERTIFICATION FORM

Instructions: This form must be completed and given to your caseworker prior to being housed. All

blanks must be completed.

Make sure you have this form available when calling the utility company so that you can fill in the

information for Date services was turned on and Utility account number. If you fail to completely fill out

this form you will not be housed.

Tenant’s (Head of Household) Name: ____________________________________________________________

Tenant’s new address:

(Address where service was turned on)___________________________________________________________

Please complete one entry below for each utility you will be responsible for (power, gas, water, trash

collection. Do Not include telephone, cable, etc.)

Name of Utility Provider Company ____________________________________________________________

Date service was turned on: ___________________ Utility account number: ____________________________

(IMPORTANT: You must get this information from the utility company when you have utility turned on)

Name of Utility Provider Company ____________________________________________________________

Date service was turned on: ___________________ Utility account number: ____________________________

(IMPORTANT: You must get this information from the utility company when you have utility turned on)

Name of Utility Provider Company ____________________________________________________________

Date service was turned on: ___________________ Utility account number: ____________________________

(IMPORTANT: You must get this information from the utility company when you have utility turned on)

ALL UTILITY ACCOUNTS MUST BE IN THE HEAD OF HOUSEHOLD’S NAME.

Failure to maintain utility service in the head of household’s name may result in the termination of

housing assistance.

By signing below, I certify that the information provided by me in this document is true and complete.

________________________________

_____________________

Tenant Signature

Date

WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS

GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT

STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES GOVERNMENT.

F:DATAFILEHousing ProgramsSection 8 ProgramFORMSUtility Verification Form REVISED 070731.doc

Utility Account Certification Form