TOWN OF HAVERHILL

RENTAL VERIFICATION FORM

THIS FORM MUST BE COMPLETED BY THE LANDLORD

Tenant’s Name:__________________________________________ Date:____________________________

Address:_______________________________________________________________________________

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

Number of Household Members:_______________ List of Household Members:______________________

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_______________________________________________________________________________________

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Occupancy date: ______________ Security Deposit: Amount: $____________ Date paid: _________________

Rent amount: $_______________ ; paid q monthly qweekly qother ______________

If subsidized rent, please list tenant portion: $_____________

Rent Includes: q All utilities q No Utilities q Hot Water q Heat q Electric

Type of Heat: q Electric q Oil q Gas q 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:

Tax ID #:____________________________ OR Social Security #:_________________________________

CHECK IS TO BE MADE PAYABLE TO: (PLEASE PRINT)

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Landlord’s Name Telephone / Fax Numbers

______________________________________________________________________________

Landlord Address

________________________________________________

Name of Manager or other Representative

___________________________________________________

Landlord Signature Date