New Jersey Department Of Community Affairs Low Income Home Energy Assistance & Universal Service Fund Programs printable pdf download

New Jersey Department Of Community Affairs Low Income Home Energy Assistance & Universal Service Fund Programs

NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS

LOW INCOME HOME ENERGY ASSISTANCE &

UNIVERSAL SERVICE FUND PROGRAMS

Tenant Lease Verification Form

(This form is to be filled out only by the landlord and/or superintendent)

This is to verify that (

tenant’s name

) __________________________________________ is residing at:

Street Address: ______________________________________________Apt. Number: ________

City, State, Zip Code _____________________________________________________________

The number of occupants in this residence is: ____________

Names of ALL members of the family living in the unit:

______________________________________________________________________________

Rent payment amount: _____________________

Please verify heating arrangement:

(

) Heat is included in rent, which is subsidized.

(

) Heat is included in rent, which is not subsidized.

(

) Tenant pays separate charge for heat.

(

) Tenant is responsible for paying his/her own heating expenses.

(

) Tenant pays separate charge for air conditioning.

Landlord’s information:

First Name: _________________________________ Last Name: __________________________

Address: __________________________________________________________________________

City, State, Zip code: ________________________________________________________________

Phone Number: _______________________________

__________________________________

_____________________

Landlord/Representative Signature

Date

New Jersey Department Of Community Affairs Low Income Home Energy Assistance & Universal Service Fund Programs