ACTION-Housing, Inc.
Emergency Rental Assistance Program
Rent and Fees Ledger for Landlords
This rental/fee ledger form is to collect the information from Landlords as to the monthly rent, fees,
and expenses, as well as the current owed amounts per month for their tenant.
**Please note that this form will be visible to the Tenant/Applicant once completed and uploaded.
Landlord Name
Tenant Name
Application #
Property Address
Please conrm the current Monthly Rent, Fees, and Expenses that the tenant is responsible for
according to the lease. Please also include a signed copy of the lease or a signed renewal that
indicates the rent amount and monthly fees agreed to between the Landlord and the Tenant.
Rent Amount
Late Fee Amount
Other Lease Fees
Other Expenses
Please include the current per-month amount of Rent, Fees, and Expenses owed by the tenant. Only
include months currently due and owing.
Please type/sign to indicate that the above amounts owed are current and comprehensive:
Landlord Signature Date
Revised 6/14/2021
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Monthly Amount Description of Fees
Months
Applying
Rent Owed
(Can be full or
partial)
Late Fees
Owed
Other Lease Fees
Owed (Parking fees,
Pet fees, etc.)
Other Expenses
Owed
(Utility fees)
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Total:
click to sign
signature
click to edit
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