Household Composition Landlord Form - Delaware Health And Social
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1DCIS # ___________________
DELAWARE HEATH AND SOCIAL SERVICES
RESIDENCE AND HOUSEHOLD SIZE
DIVISION OF SOCIAL SERVICES
VERIFICATION FORM
From:________________________________________________
Re:_____________________________
DSS Address:__________________________________________
Residence:_______________________
_____________________________________________________
________________________________
Pool Number:___________Telephone:______________________
Mailing Address (if different from residence)
__________________________________
Fax Number:____________E-mail address:__________________
Case Number:_______________________
Date:______________________________
Dear Landlord/Collateral Contact/Mortgagee:
The person listed above is applying for or receiving benefits from Social Services. To determine eligibility, we need to
verify the person’s address and shelter expenses, identify all household members and their relationship to each other. If
the above address is incorrect, please list the address on record. __________________________________________
_________________________________________________________________________________________________
Please list all household members and the relationship to each other.
(If you are the landlord, the leaseholder or mortgagee
and live at the same address, please include your name and list your relationship to the other individuals.)
_______________________________ _______________________________ _______________________________
_______________________________ _______________________________ _______________________________
_______________________________ _______________________________ _______________________________
Total number of household members is __________________.
Shelter costs: Please check all that apply to the above person and list the amounts paid:
___ (1) There is no charge for rent.
___ (2) Tenant pays rent (including lot rent). The charge is $_______________ monthly or $_______________ weekly.
___ (3) Tenant receives Section 8 subsidized housing and pays $_________out of pocket each month.
Utility costs: Please check all that apply to the above person and list the amounts paid:
___ (1) There is no charge for utilities.
___ (2) Tenant pays for heat separate from rent.
The type of heat is ___Electric ___Gas ___Oil ___Kerosene ___Wood ___Coal $____________
___ (3) Tenant pays for air conditioning.
___ (4) Tenant pays separately for:
___Electric $_____
___Gas (nonheat) $_____
___Sewer $_____
___Trash $______
___Water $_____
___Other $_____
___ (5) Tenant only pays for excess heat or cooling costs. The monthly excess amount is $__________________
___ (6) Tenant receives a HUD/WHA utility allowance each month. The amount of $________ is applied to the rent
or received by client.
___ (7) Tenant moved in on _________________ and started paying charges for month of ___________________
Check the eating arrangements for the person listed above if you, the landlord, live at the same residence:
___ (1) Tenant (and tenant’s family) purchases and prepares meals separately from you.
___ (2) Tenant (and tenant’s family) purchases and prepares meals with you.
___ (3) Tenant (and tenant’s family) pays you for meals. If checked, what is the monthly amount $__________
Meals are provided to the tenant at no charge.
___ (4)
I UNDERSTAND THAT I AM NOT TO SIGN THIS FORM IF IT HAS ALREADY BEEN COMPLETED PRIOR TO BEING GIVEN TO ME. I
UNDERSTAND THAT STATE LAW PROVIDES CRIMINAL PENALTIES FOR INTENTIONALLY GIVING FALSE INFORMATION TO HELP
SOMEONE GET CASH ASSISTANCE, FOOD STAMPS AND/OR MEDICAID.
__________________________________________ ___________________ ___________________
SIGNATURE OF LANDLORD/THIRD-PARTY CONTACT/MORTGAGEE
DATE
PHONE NUMEBER
_____________________________________________________________________________________
ADDRESS
____________________________________
I hereby give permission for the release of the above information.
APPLICANT/REPRESENTATIVE SIGNATURE DATE
PLEASE DROP OFF, MAIL OR FAX THE FORM TO THE DSS ADDRESS OR FAX NUMBER LISTED ABOVE.
FORM 176 (REV. 11/2010)
Document No. 350701-01-11-02
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