Form Ldss-3668 - Shelter Verfication
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2LDSS-3668 (Rev. 2/10)
SHELTER VERFICATION
Local District Name and Address:
Case Number:
Worker ID:
Case Name and Address:
Dear Sir/Madam:
We are currently reviewing the assistance case of the above named person. In order to complete our evaluation of this
case, we need information regarding household composition and shelter expenses. This form is for verification purposes
only, and does not imply any obligation on the part of this Agency.
Please complete this questionnaire beginning with Section A below. Thank you for your cooperation.
SECTION A: SHELTER DESCRIPTION
Type of Dwelling (Check One)
Address:_______________________________
Hotel/Motel
Room in Private Home
City:__________________________________
Apartment (# ____ )
Commercial Rooming House
Are Meals Included?
House
Trailer
Yes
No
Zip Code:______________________________
No. of Bedrooms: ____
Is any part of the room rent used
for heat or utilities?
County:________________________________
Yes
No
SECTION B: HOUSEHOLD COMPOSITION
Number of people living in this rental unit: ______________
How long has this person lived
How long has this person lived
Names
Names
here?
here?
Does anyone listed above have a telephone?
Yes
No
Is anyone listed above employed?
Yes
No
Number: ________________________________________
Name: _________________________________________
Employer:_______________________________________
Does anyone listed above perform any services for you for
Do you have any employment opportunities for a member
which he/she receives a lower rent?
Yes
No
of this household?
Yes
No
If yes, explain: ___________________________________
If yes, explain: ___________________________________
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