015 Charles Town Horsemen Landlord Verification Cthbpa printable pdf download

Charles Town Horsemen’s Assistance Fund, Inc.

Landlord Verification Form

Applicant Name: ___________________________________________________

Date: ____________________

Applicant’s Physical Address: __________________________________________________________________________

___________________________________________________________________________________________

Applicant’s Phone Number: ___________________________________________________________________________

**************************************************************************************************

To the Landlord/Property Owner:

The above applicant has applied to the Charles Town Horsemen’s Assistance Fund, Inc. (CTHAF) for assistance in paying

their rent. Please fill out the below information, sign and date the form, and return with a copy of the applicant’s lease

for verification purposes.

Landlord’s Name: ___________________________________________________________________________________

Landlord’s Phone Number: ____________________________________________________________________________

Landlord’s Mailing Address: ___________________________________________________________________________

___________________________________________________________________________________________

Property Owner’s Name (if different from the Landlord): ____________________________________________________

Property Owner’s Phone Number: ______________________________________________________________________

Property Owner’s Mailing Address: _____________________________________________________________________

___________________________________________________________________________________________

If Landlord is different from Owner, please provide explanation of the relationship between Landlord and the owner.

___________________________________________________________________________________________

The above Applicant has resided in the rental property since: _______________________________________________

Who else lives with Applicant in rental property: __________________________________________________________

___________________________________________________________________________________________

The Applicant is obligated to pay $_______________ per month or week (circle one).

The Applicant owes the following for past due rent and late fees: $__________________ is the total due made up of:

$________________

Rent for the period of time: _______________________ to ______________________

$________________

Late fees for the period of time: ____________________ to ______________________

I/We, the Landlord and/or Property Owner of the above reference rental property, under the penalties of perjury,

verify that all information provided herein to the CTHAF is true and accurate. I understand that if I provide false

information to obtain rental payments that are not due, I will be obligated to return all monies paid and may face

both civil and criminal charges for these false representations.

______________________________________________

_____________________________________________

Landlord

date

Property Owner

date

015 Charles Town Horsemen Landlord Verification Cthbpa