Southern Nh Services Rockingham Community Action

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FAP FORM # 1
Southern NH Services/Rockingham Community Action
LANDLORD VERIFICATION
TO LANDLORD: Please read the following and complete the reverse side.
Your tenant is applying for the Fuel Assistance Program (FAP). In order to assist us in determining
his/her eligibility, we must have accurate information. It is mandatory that all renters have a Landlord
Verification Form completed by the landlord. They cannot get a benefit without this form.
Please make sure all information requested is completed and correct on this form.
• If this household is found to be eligible and heat is not included in rent, a credit will be issued to
the tenant’s fuel vendor.
• If heat is included in rent and the rent is not subsidized, FAP will provide assistance in the form
of rent voucher(s). The voucher will be issued for the amount of the benefit, but no more than
the tenant’s monthly rent amount. This may be repeated for a specific number of month(s) until
the benefit amount has been spent. If your tenant’s rent is overdue, please fill in the amount
past due on the reverse side. If your tenant pays by the week, make sure to calculate what will
be owed for that week plus the remainder of the month. We do not pay by the week.
• Checks will be issued within 15 working days of receipt of signed vouchers.
Any landlord who qualifies to receive payment from the Fuel Assistance Program must have a W-9 on
file. This must be accompanied with a photocopy of owner's Social Security number or Federal ID
number for verification purposes. Corporations, Partnerships or Trusts, must submit either stationery
which has the Federal Identification number imprinted on the letterhead or a copy of the IRS label/tax
form with the completed W-9.
The Fuel Assistance Program can pay rent owed from Oct. 1, 2014 but only when the heat is included
in the rent, and only after the beginning of the program in December 2014. Rental payments cannot
be applied to security deposits or to application fees. Failure to comply with these rules will prohibit,
you the landlord, from participating in the program.
It is the applicant’s responsibility to bring or FAX the completed form back to us at the area office that
is circled below where he/she applied for assistance.
ATTENTION:_____________________________________TEL.#___________________________EXT.#_______
Southern NH Services/Rockingham Community Action
Fuel Assistance / Electric Assistance Program
Permanent Sites:
Portsmouth Office
Raymond Office
Seabrook Office
Salem Office
Derry Office
4 Cutts St.
55 Prescott Rd.
683 Lafayette Rd
85 Stiles Rd., Ste 103
9 Crystal Ave.
Portsmouth 03801
Raymond 03077
Seabrook 03874
Salem 03079
Derry 03038
FAX: 603-430-4926
FAX: 895-2330
FAX: 474-8728
FAX: 893-6723
FAX: 965-3049

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