Form Ldss-3668 - Shelter Verfication Page 2
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2SECTION C: SHELTER EXPENSES
Rental Amount: $______________________________________
Is rent paid up to date?
Yes
No
Due:
Weekly
Monthly
Every 2 weeks
Twice a month
Last month that rent was paid in full: ___________
Name of person(s) paying rent: ___________________________
Is rent subsidized? (e.g. HUD)
Yes
No
Name of Tenant of Record: ______________________________
If yes, amount subsidized: ___________________
(If different from person paying the rent)
Subsidizing agency: ________________________
Check the following which are included in the rent:
Heat
Electricity
Hot Water
Air Conditioning
Furniture
Garbage Collection
Stove
Refrigerator
Water/Sewer
Cooking Fuel
Meals
Heating Equipment
If heat is not included in rent, check the primary type of fuel used for heating :
Natural Gas
Kerosene
Propane
Coal
Wood
Electricity
Oil
Does the furnace/stove heat:
Only this apartment
Entire House
Other (Specify): ________________________________________
Does the tenant pay to you an amount, separate from the rent, for heat?
Yes
No
If yes, list monthly amount:_______________________
If no, does the tenant pay the vendor directly for heat?
Yes
No
Does the tenant pay to you an amount, separate from the rent, for water?
Yes
No
If yes, list monthly amount: _________________________________________________
Does the tenant pay to you an amount, separate from the rent, for other non-heating utilities?
Yes
No
If yes, list monthly amount: _________________________________________________
If tenant pays for non-heating utilities, are there separate meters for the tenant’s apartment?
Yes
No
To your knowledge, does anyone that lives outside of the household pay all or part of the rent and/or utilities?
Yes
No
If yes, please explain: _____________________________________________________
SECTION D: LANDLORD INFORMATION
Date Tenant moved in / will move in:
Does Landlord live in the same apartment/ rental unit as
Yes
No
tenant?
Relationship to Tenant:
Landlord’s Name:
Landlord’s Address:
Landlord’s Telephone Number:
Landlord’s Signature:
Landlord’s E-mail Address:
Date:
Owner’s Name (If different than landlord):
Owner’s Address:
Owner’s Telephone Number:
Owner’s E-mail Address:
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