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Fuel and Electric Assistance Program

Landlord/Housing Verification

If heat is included in housing cost, this must be completed & signed by the Landlord/HOA/Condo Assoc.

Property Owner Name _____________________________ Manager Name __________________________ Mailing Address _______________________________ City ______________ State ____ Zip Code _______ Email address ____________________________________ Phone ________________________________

Tenant Name _____________________________________ Phone _______________________________ Rental Address ____________________________________ City _______________ Zip Code __________ Initial Date of Occupancy _________________ Number of adults (18+) ______ Number of children ______ Please list the name(s) of everyone living in the household: _______________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Monthly Rental Amount: $__________ Is rent past due? ☐ Yes ☐ No If yes, by how much $_________ Is rent subsidized? ☐ Yes ☐ No If yes, tenant portion: $_____________/mo Rental is: ☐ Apartment ☐ Condo ☐ Duplex ☐ Mobile Home ☐ Single Family ☐ Room ☐ Hotel/Motel Is there a Condo Association or HOA fee with heat included? ☐ Yes ☐ No # of Rooms in Home: Bedrooms ___ Bathrooms ___ Kitchen __ Dining Rm __ Living Rm __ Total Rooms ___

Primary Heat Type ☐ Oil ☐ Kerosene ☐ Propane ☐ Electric ☐ Natural Gas ☐ Wood ☐ Pellets Secondary Heat ☐ Oil ☐ Kerosene ☐ Propane ☐ Electric ☐ Natural Gas ☐ Wood ☐ Pellets ☐ None

Utilities Included: ☐ Heat* ☐ Electric ☐ None

By signing this form, I swear that the above information is true, complete, and accurate. I understand that if I knowingly give inaccurate or incomplete information pertaining to the tenant’s eligibility for the program(s), I am breaking the law and can be prosecuted; conviction may result in imprisonment and/or fine.

If heat is included in rent or association costs, I acknowledge that I have reviewed both pages of this agreement and that this agreement is legal and binding and affix my signature with the understanding that I do so under penalty of perjury. _______________________________________________ ________________ PROPERTY OWNER/MANAGER’S SIGNATURE DATE ________________________________________________ ________________ PROPERTY OWNER/MANAGER (Print Name)

DATE *Heat Included? Review & complete page two! Do not include closets/pantries, hallways, unheated attics/basements/porches, etc.