Landlord Information Form - Leech Lake Band Of Ojibwe Tribal Assistance Office (Page 2 of 2) in pdf

Landlord Information Form - Leech Lake Band Of Ojibwe Tribal Assistance Office Page 2

Landlord Information Form Continued

Yes

Are there operable smoke detectors in the unit?

Yes

Is there an operable fire extinguisher in the unit?

Yes

Is there an operable carbon monoxide detector in the unit?

Yes

Is there an operable heating source in the unit? What type of heat? ___________________

Yes

Has the unit been declared unfit for habilitation by an agency or unit of government?

Yes

Is there separate electrical service?

Yes

Is there separate heat service?

Yes

Is the dwelling a separate dwelling from the landlord?

If you have answered NO to any of the above questions, the Tribal Assistance Program reserves the right to deny

rental assistance.

Directions to unit (from Cass Lake) _____________________________________________________________

__________________________________________________________________________________________

Owner Data

Check for rent shall be made payable to __________________________________________________________

Owners Legal Name ________________________________________ Phone __________________________

Owner’s Residence/Office Address, include street address, city, state, zip and county:

__________________________________________________________________________________________

Owner’s Mailing Address, if different from above:

__________________________________________________________________________________________

Name of person completing form _______________________________________________________________

Title ______________________________________________________ Phone __________________________

I hereby certify that the above information is complete, true and correct:

Signature __________________________________________________ Date ___________________________

Agency info ________________________________________________ Phone __________________________

Contact ___________________________________________________ Fax ____________________________

Tribal Assistance Use ONLY:

Verification of home and land ownership is required to be verified

Accepted Verification Source:

County Assessor

County Auditor

County Recorder

TA/06272013/DP

Leech Lake Band of Ojibwe Tribal Assistance Office • 115 Sixth Street NW, Cass Lake, MN 56633 • (218) 335-3626

Landlord Information Form - Leech Lake Band Of Ojibwe Tribal Assistance Office Page 2