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Department of Workforce Services

DWS-HCD 1062H

Rev 08/2014

LANDLORD STATEMENT

This form must be completed and signed by the landlord (property owner) or the residence manager of applicant.

Date: __________________________ Tenant name: ________________________________________________________________

Tenant address: ______________________________________________________________________________________________

Legal name of the landlord: ____________________________________________________________________________________

Are you related to the tenant?  Yes  No

Do the tenant and landlord reside at the same address?  Yes  No

This rental unit is a

 House

 Apartment

 Duplex

 Basement apartment

(check one):

 Mobile home

 Small trailer

 Room

 Condo/townhouse

This rental unit is heated by

 Gas

 Electricity

 Steam

 Coal

(check one):

 Wood

 Propane

 Fuel oil

Monthly rent the tenant is responsible for: $_______________________________________ Is the rent subsidized?  Yes  No

Does the tenant work for part of the rent?  Yes  No If yes, how much? $ __________________________________________

Number of occupants residing in the rental unit: ___________

Is either the gas or electricity in the tenant’s name?  Yes  No If yes, which type of energy:  Gas  Electricity

Please check one of the following:

1.  A portion of the rent paid by the tenant is used to pay the cost of gas, electricity, or both.

2.  The above named tenant receives a utility allowance and the utility allowance is specifically

identified in the tenant’s lease.

3.  The utilities are in the landlord’s name, however, the tenant is responsible to pay the utility bills.

The reason the utilities are in the landlord’s name is (check one):

 a. A city utility company requires the landlord to list utilities in the landlord’s name.

 b. Tenants could not establish service in their name due to past-due bill, deposits not paid, etc.

 c. I prefer to know how large the bill is and that the bill is getting paid.

 d. Other reason: __________________________________________________________________________________

4.  The above named rental project receives a rental and utility subsidy from either HUD or Rural Development.

The rental project, not the tenant, receives the rent and utility subsidy. The tenant does not pay any utility costs out of

his/her own pocket.

Please print and sign your name below. Include a phone number where you may be reached and attach a business card if possible.

Name (print): ____________________________________________ Signature: _________________________________________________

Date: ______________________ Phone: ___________________________ Position/title: _________________________________________

Landlord’s address: __________________________________________________________________________________________________

Contact the local HEAT Office with questions: ______________________________________________ Phone: _______________________

Equal Opportunity Employer Program

Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240.

Individuals with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.

Form Dws-Hcd 1062h - Landlord Statement Form - Department Of Workforce Services - Utah

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