General Assistance Rental Verification Form

General Assistance Rental Verification Form

LANDLORD / PROPERTY MANAGER MUST COMPLETE
Name of person (property manager/landlord) submitting this form.*

First NameLast Name
Email of person (property manager/landlord) submitting this form.*
example@example.com
Phone number of person (property manager/landlord) submitting this form.*
Please enter a valid phone number.
Please upload the W-9*

Cancelof
DOING BUSINESS AS:*
BUSINESS TAX ID #*
CONFIMATION OF WHERE FORM 1099 IS TO BE SENT TO:*
ATTENTION
ADDRESS OF WHERE FORM 1099 IS TO BE SENT TO:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PLEASE TELL US WHERE THE RENTAL ASSISTANCE PAYMENT SHOULD BE MAILED TO:*
ATTENTION:
ADDRESS OF WHERE THE RENTAL ASSISTANCE PAYMENT SHOULD BE MAILED TO:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I First Name* Last Name* BEING THE LANDLORD / PROPERTY MANAGER STATE THE FOLLOWING INFORMATION ON THE RENTAL PROPERTY LISTED BELOW TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
RENTAL PROPERTY ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ALL OCCUPANTS ON THE LEASE*

First NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
START OF LEASE / RENTAL AGREEMENT:*

MonthDayYear
Date
MONTHLY RENT AMOUNT:*
REQUESTING ASSISTANCE FOR MONTH OF:*

UTILITIES INCLUDED IN RENT:*

IS THERE PAST DUE RENT?*

YESNO
IF YES, WHAT IS THE AMOUNT & WHAT MONTHS ARE OWED:
IF APPLICANT IS DETERMINED ELIGIBLE, I WILL ACCEPT A CHECK FROM WARREN COUNTY GENERAL ASSISTANCE FOR THE CURRENT MONTH’S RENT AND UNDERSTAND THAT THE OCCUPANTS MAY NOT BE EVICTED FOR FAILURE TO PAY RENT DURING THIS COMPLETE 30-DAY PERIOD. A CHECK WILL BE ISSUED PAYABLE ONLY TO THE INDIVIDUAL OR BUSINESS NAME SPECIFIED ON THE LEASE/RENTAL AGREEMENT.
LANDLORD / PROPERTY MANAGER'S SIGNATURE*

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