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Households with Heat Included in Housing/Rent– Fuel Assistance Agreement

For eligible households with heat included in rent/housing cost, Fuel Assistance Program benefits will be paid directly to the landlord (or HOA/Condo association). Please review the important information below: • As heat is included in rent, the property owner assumes full responsibility for heating the premises. • If the tenant is eligible for an assistance benefit, the agency will make a payment to the property owner. • Payments will be made payable and sent to the name and address indicated below. • The property owner agrees that the named tenant’s rent/cost will be reduced by the payment amount. • The property owner agrees that the rent shall not increase because of the benefit payment. • The property owner agrees that, should the tenant move out before the full amount of the benefit is utilized, the owner will refund any unused portion of the benefit to the tenant directly. • The property owner affirms that the named tenant’s rent is not subsidized, in part or whole, by State or Federal Housing program. Tenants with subsidized rent AND heat included in rent are not eligible.

For mailing purposes only, please indicate who the payment should be mailed to (select one): ☐ Property Manager ☐ Property Owner ☐ Condo or Homeowners Association

Name and address for payment below: Name _____________________________________________________________________________ Physical Address _____________________________________________________________________ Mailing Address ______________________________________________________________________ City ___________________________ State __________________ Zip Code ____________________

Payment will be made within 45 days after the date the benefit notification is sent.

NOTE: A requirement for payment is an updated W-9 IRS Form for the person/entity named above.