Fillable Printable Rental Verification Sample Form

Rental Verification Sample Form

RENTAL VERIFICATION FORM

THIS FORM MUST BE COMPLETED BY THE LANDLORD

Tenant’s Name: ________________________________________ Date: ___________________________

Address: _______________________________________________________________________________

(Number/Street) (Apt. #) (City) (State)

Number of Household Members:______________ List of Household Members: ______________________

______________________________________________________________________________________

Occupancy date: _____________ Security Deposit: Amount: $ ____________ Date paid: _____________

Rent amount: $ _______________; paid  monthly weekly other ______________

If subsidized rent, please list tenant portion: $_____________

Rent Includes:  All utilities  No Utilities  Hot Water  Heat  Electric

Type of Heat:  Electric  Oil  Gas  Other ______________

Date last rent was paid: _____________ Amount Paid: $ ___________ Back rent owed: $ _____________

(if back rent is owed, please attach accounting of months and amounts)

For IRS reporting, landlord’s Tax ID or Social Security # must be provided:

Tax ID #: ___________________________ OR Social Security #: ________________________________

CHECK IS TO BE MADE PAYABLE TO: (PLEASE PRINT)

_______________________________ ____________________________________

Landlord’s Name Telephone / Fax Numbers

______________________________________________________________________________

Landlord Address

______________________________________________

Name of Manager or other Representative

_______________________________________________ ___________________________________

Landlord Signature Date