RENTAL VERIFICATION FORM

THIS FORM MUST BE COMPLETED BYTHE LANDLORD

Tenant’s Name:________________________________________Date:___________________________

Address: _______________________________________________________________________________

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

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:

______________________________________________________________________________

Landlord Address

______________________________________________

Name of Manager or other Representative

__________________________________________________________________________________

Landlord Signature Date