Fillable LANDLORD OR ROOMMATE UTILITY ASSISTANCE INFORMATION FORM (This (Eastern Shawnee Tribe of Oklahoma)

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LANDLORD OR ROOMMATE UTILITY ASSISTANCE INFORMATION FORM (This (Eastern Shawnee Tribe of Oklahoma)

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BROWSE EASTERN SHAWNEE TRIBE OF OKLAHOMA (OK) FORMS

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LANDLORD OR ROOMMATE UTILITY ASSISTANCE
INFORMATION FORM
(This form must be completed by the landlord or roommate)
Name of tribal member (tenant): ______________________________________________________
Billing information as it appears on the utility statement:
Name: _______________________________________________________________
Address: _____________________________________________________________
_____________________________________________________________
Relationship to tribal member: ________________________________________________________
How long has tribal member been at this residence: _______________________________________
Are utilities included with rent cost? Yes No
If yes, please breakdown cost for each utility charged: ______________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Is the lease/rental agreement attached? Yes No
If no, please explain why: ____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How many residents reside at this residence: __________________
Landlord/Roommate Signature: ____________________________________ Date: _____________
(Whose name appears on the utility bills)
Telephone number where you may be reached: __________________________________
Tribal Members Signature: ________________________________________ Date: _____________
Please submit utility statements with proof of payment from tribal member, i.e. money order,
cashier’s check or cancelled check (front & back) and mail to:
Eastern Shawnee Health & Social Service Department
10100 S. Bluejacket Rd., Ste. 1
Wyandotte OK 74370
Feel free to contact the department with any questions you may have at 918-666-7710
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LANDLORD OR ROOMMATE UTILITY ASSISTANCE INFORMATION FORM (This (Eastern Shawnee Tribe of Oklahoma)

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Completed 20 July 2020

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