Shelter Verification Form printable pdf download

To Be Completed by Landlord Only

I.M.310

SHELTER VERIFICATION FORM -

Please check one:

□

Grey Area for Agency

SHELTER DESCRIPTION

New Move

Use Only

Tenant Name:

________________________________________________________

□

Add Individual

Address: Street: ____________________________________ Apt ________

□

Violations on

Rent Increase

City_________________________ County___________ ZIP: _____________

□

Property ?

Other:

 Yes

 No

Dwelling Type: SHA Public Housing

 Facility and # of Bedrooms: ____

 Apartment

 House

 Trailer

 Hotel/Motel Room

 Other: ________________

If yes, check one:

 Room & Board (meals included)  Commercial Rooming House – Are meals included?  Y  N

 Stop Rent

 Room in private home (no meals) - Is any part of rent used by landlord for heat/utilities?  Y  N

 Unfit

PERSONS RESIDING AT ABOVE ADDRESS/HOUSEHOLD COMPOSITION

“Reference Icon”

Date Tenant Moved In or Will Move In: ______________

checked for Street

Name(s) of Persons(s) Responsible for Paying Rent: _______________________________________

listing ?

Name(s) of Any Other Person(s) Paying Rent: ____________________________________________

 Yes

 No

List All Persons Living at this Address:

Total Number of Persons: _________

Names:

Relationship to Tenant:

Date Moved In:

 Tenant of

___________________________________

____________________

_______________

Record Verified

___________________________________

____________________

_______________

Name::

___________________________________

____________________

_______________

_________________

___________________________________

____________________

_______________

_________________

___________________________________

____________________

_______________

Use back side if more space is needed to list household members.



WMS Clearance

Is the landlord related to anyone listed above?  Yes  No Relationship: ______________________

checked For all NTA

Does the landlord live in the same apartment/rental unit as the tenant?  Yes  No

HH members.

Was a Cash Security Deposit paid by the tenant?  Yes  No If Yes, Amount Paid: ____________

Contribution

Are you requesting a DSS Security Deposit Agreement?  Yes  No For more information see

Statement needed?

Renting to a TA Client at

 Yes

 No

SHELTER EXPENSES

Is rent paid up-to-date?  Yes  No

 Fuel Type Verified

Amount of total monthly rent:

___________________

If no, for what month(s) does

__________________

the tenant owe? _________________

Is Rent Subsidized?  Yes  No

Amount of rent owed: $ ___________

Subsidy Amt:

_________________

Fuel Vendor Name:

This is for informational purposes only. DSS does not

: $

Tenant’s Share

_________________

__________________

guarantee money owed for back rent.

__________________



Landlord requires tenant agree to rent voucher up to maximum grant

Customer of Service:

Check which of the following are included in the rent:

__________________

 Heat

 Air Conditioning  Stove

 Refrigerator

 Water/Sewer  Electricity

Heat/Utility Acct. #:

 Cooking Fuel  Garbage Collection  Hot Water  Furniture  Other: ________________

__________________

If heat is not included in the rent, check the fuel type used and indicate the vendor: Oil

__________________

 Natural Gas  Kerosene  Wood  Electricity  Propane  Coal Vendor: _______________

If non-heating utilities are not included in the rent, indicate the type of utilities and the vendor:

Owner verified through

 Electricity: ________________  Cooking Gas: _______________  Water: ________________

ONGOV.net

Does the tenant pay you an amount, separate from the rent, for: heat?  Y  N Amount: $_________

Owner name:

__________________

Other non-heating utilities? Amount: $ _______ Water?  Y  N Amount: $ ___________

__________________

Does anyone from outside of the household pay all or any part of the rent, fuel or utilities?  Y  N

If yes, please explain: ________________________________________________

Does anyone perform any services for you for which he/she receives a lower rent?  Y  N

LANDLORD/OWNER

Collateral Contact

If anyone other than the Property Owner, you MUST supply a copy of the Management Agreement, LLC, Trust or other authorizing

Date: ____________

paperwork outlining who is authorized to sign and receive rents. The LL Statement will not be processed without this information.

Landlord Name

): _______________________________ Day Phone #: ________________

(Please print

Worker name:

Address: _________________________________________________________________________

__________________

Vendor ID: _______________________

______________________

Owner of Property (

): _______________________________________________

If different from above

Case # :

Address: ________________________________________________ Day Phone #: ______________

__________________

Signature of Landlord:______________________________ Date: ___________________________

Shelter Verification Form

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