LANDLORD/UTILITY FORM
Applicant and Landlord Information are required. Utility Information is required only if applicant is requesting assistance for utilities.
If applicant is requesting assistance for more than one utility provider, this form will be required for each utility which assistance is
being requested.
APPLICANT INFORMATION
(MUST BE COMPLETED BY APPLICANT)
Name____________________________________ Address____________________________________
___________________________________________
Applicant Print Name: _____________________________________________
Applicant Signature: ______________________________________ Date:_______________________
LANDLORD INFORMATION
(MUST BE COMPLETED BY LANDLORD)
Name____________________________________ Address____________________________________
Phone____________________________________ ___________________________________________
Email____________________________________
Tax Identification Number (Required) ______________________________________
Does the tenant have overdue rent charges? YES NO
If yes, overdue balance due to unpaid rent charges: $___________________
Regular Monthly Rent and Monthly Utility Charges (if included): $___________________
By signing below, I hereby certify (check all that apply):
All information listed above is correct and applicant is a current tenant of my property.
The tenant is behind due to the COVID-19 Public Health Emergency and is at risk of eviction if these charges
are not satisfied. I also certify that the tenant’s overdue balance relates to charges obtained no earlier than March
13, 2020, the date of the emergency declaration pursuant to section 501(b) of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act, 42 U.S.C. 5191(b).
Landlord Print Name: __________________________________________
Landlord Signature: ______________________________________ Date:_______________________
UTILITY PROVIDER INFORMATION
(MUST BE COMPLETED IF UTILITY ASSISTANCE IS REQUESTED – MAY BE COMPLETED BY APPLICANT OR
UTILITY PROVIDER)
Utility Provider Name___________________________ Accountholder’s Name _________________________
Tax Identification Number ______________________ Account Number_______________________________
(Required)
Utility Type: Electric Water Gas/Propane Sewer Trash
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