Landlord Verification Form Page 2
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2LANDLORD VERIFICATION
Part I
__________________________________
Tenant’s Name
___________________________________________
Name of Department Worker
_________________________________________
Tenant’s Address
Return completed form by _____/_____/_______
_________________________________________
City/Town
ZIP
Part II (
Please complete, sign and date this form.)
A. Rental Information
1. The total rent for this address is: $_________ per
month
week
other ________ (specify)
2. Does the tenant live in:
Public Housing?
Yes
No
Section 8 or Massachusetts Residential Voucher Program?
Yes
No
3. If subsidized: Tenant Payment is:
$_________ per
month
week
other ________ (specify)
4. Is the tenant behind on the rent?
Yes
No
B. Utility Information
1. Are heat/air conditioning and all other utilities included in the rent?
Yes
No
2. If not, does the tenant pay for any of the following separate from the rent?
Utilities
Heat
Air conditioning
Electric
Gas for cooking
C. Landlord Information
Landlord's Signature __________________________________________________________________________________
Landlord’s Name (print) ___________________________________________________ Date _____/_____/__________
Landlord’s Address___________________________________________________________________________________
Landlord’s Daytime Telephone Number (_____) ______ - __________
LL/VER (Rev. 1/2008)
18-083-0108-05
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