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APPENDIX L

LIHEAP Landlord Verification Form HEATING AND COOLING UTILITIES INCLUDED IN RENT VERIFICATION

Applicant’s Name

Address

Application ID#

Telephone Number

Landlord/Manager Name

Address ___________________________

Telephone Number

Are heating and or cooling utilities included in the rent? ________________________

Are you disconnected for an overdue heating or cooling bill? _______________ _____

Are you in danger of disconnection for an overdue heating or cooling bill?

Is your heating/cooling bill past due? ____________________________________ Rental Unit’s Monthly Heating Cost ________________ Cooling Cost __________________ How was this amount determined? (Please provide support)

I/We (Landlord(s) Name) agree to offset the rent for (Applicant’s Name) in the amount of the total LIHEAP assistance benefit received on their behalf.

Landlord/Manager Signature

Date

SUBGRANTEE VERIFICATION (if applicable): Subgrantee Verified Signature

Date Landlord/Manager contacted (if needed)

Effective: April 1, 2026