Southern Nh Services Rockingham Community Action (Page 2 of 2) in pdf

Southern NH Services/Rockingham Community Action

FUEL ASSISTANCE /ELECTRIC ASSISTANCE PROGRAM

Landlord Verification Form

This form must be completed and signed by the Landlord or Manager

OWNER’S NAME: ____________________________________________________________________________

PLEASE PRINT

ADDRESS: __________________________________________________________________________________

CITY: ____________________________________ STATE______ ZIP_________ TEL____________________

OWNER’S EMAIL: ___________________________________________________________________________

MANAGER’S NAME:_________________________________ TEL_________________________

TENANT'S NAME: ___________________________________________________________________________

ADDRESS: ___________________________________________________APT #_________________________

CITY: ____________________________________ STATE______ ZIP__________TEL____________________

# OF ADULTS (18+): _______ # OF CHILDREN (Under 18):_________ Date of Occupancy: _________________________

Please list the name of everyone living in the household:

1_______________________________ 2________________________________ 3________________________________

4_______________________________ 5________________________________ 6________________________________

Rental amount per month: $_________________ If PAST DUE: Month____________ Amount $___________________

Please note that City Welfare or Town Rental Assistance is not a subsidized program..

Is the tenant responsible for the FULL amount of the rent?

___ YES

___ NO

If not, Agency Paying __________________________________ Tenant portion of the basic rent $__________

Please circle the appropriate answers:

included in rent

Utilities

Heat

Electricity

None

PRIMARY fuel type:

Natural Gas

Electricity

Oil

Propane (LPG)

Kerosene

Wood

SECONDARY fuel type:

None

Natural Gas

Electricity

Oil

Propane (LPG)

Kerosene

Wood

Total number of rooms: _______

DO NOT COUNT bathrooms and hallways.

HOUSING TYPE:

SINGLE HOUSE

DUPLEX

MULTI-FAMILY (3+ Apts.)

MOBILE HOME

ROOM

Is the fuel tank shared with other units? Yes ____ No ____

IT IS MANDATORY THAT ALL RENTERS HAVE THIS FORM COMPLETED!

•

If a benefit is approved and HEAT IS INCLUDED IN THE RENT, payment will be made payable and sent to the NAME

AND ADDRESS LISTED ABOVE IN THE OWNER SECTION.

•

If a benefit is approved and HEAT IS NOT INCLUDED IN RENT, a credit will be issued to the TENANT’S FUEL

VENDOR.

. I

BY SIGNING THIS FORM THE LANDLORD/MANAGER SWEARS THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE

understand that if I knowingly give inaccurate or incomplete information pertaining to the tenant’s

eligibility for the program(s), I am breaking the law and can be prosecuted; conviction may result in

imprisonment and/or fine.

THANK YOU.

________________________________________________

____ ________________

OWNER/MANAGER’S SIGNATURE

DATE

Southern Nh Services Rockingham Community Action Page 2

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