Certificate Of Rent Paid
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1Wrexham County Borough Council
FINANCIAL SERVICES DEPARTMENT, LAMBPIT STREET, WREXHAM LL11 1WS
Telephone No. (01978) 292033
CERTIFICATE OF RENT PAID
- To be completed by the Landlord
Landlord’s Full Name, Address and Post Code
Name, Address and Post Code of Agent (if applicable)
Telephone No.
Telephone No.
I am the Landlord/Agent of (address)
and my tenant (name)
is charged
(rent) every
(period) from
(date required)
for a house / flat / room (please delete as appropriate)
On what date was the rent last increased?
WHEN DID THIS TENANT MOVE IN?
LENGTH OF TENANCY
Are you related to this tenant?
Yes
No
Are you the parent of a child for whom this tenant is responsible?
Yes
No
(A) DOES THE RENT INCLUDE:
WATER RATES
YES
NO
£
IF ‘YES’, PLEASE STATE WEEKLY AMOUNT OF WATER RATES INCLUDED
(B) DOES THE RENT INCLUDE:
Any of the following amenities (if ‘Yes’ please state weekly amounts)
Heating (for Tenant only)
Yes
No
£
per week
Lighting (for Tenant only)
Yes
No
£
per week
Heating (for Shared areas)
Yes
No
£
per week
Lighting (for Shared areas)
Yes
No
£
per week
No
£
per week
Hot Water
Yes
Fuel for Cooking
No
£
per week
Yes
Yes
No
£
per week
Meals (please specify which below)
General counselling & support
£
per week
Yes
No
(Incl. Emergency Alarm systems)
(NOTE: Further details of this may be required)
£
per week
Personal and Medical care
Yes
No
Anything else (please specify below)
£
per week
Yes
No
IT IS AN OFFENCE TO DELIBERATELY WITHOLD INFORMATION OR TO MAKE A STATEMENT KNOWING IT TO BE FALSE.
N.B. THIS CERTIFICATE MUST BE SUBMITTED TOGETHER WITH THE COMPLETED HOUSING BENEFIT APPLICATION FORM.
I DECLARE THAT THE INFORMATION GIVEN ON THIS FORM IS CORRECT AND COMPLETE.
Landlord/Agents signature
Tenant’s signature
Date:
Date:
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Parent category: Business