Applicant's Name:
Self-Verification of Landlord/Tenant Relationship and Rent Owed
Rental Property Address:
Landlord's Name (name where rent is sent):
Landlord's Address:
Landlord's Phone:
Landlord's Email:
Landlord is the management company authorized to manage the property?
Yes No Unknown
Applicant Move-in Date:
Expiration of Tenancy (if any, not required):
Monthly Rent Payment:
Rent Past Due:
Are any utilities included in the rent payment? Yes No
If yes, please list:
I understand that I may need to provide additional information or answer additional questions because I am not able
to produce a written lease or a Verification of Landlord/Tenant Relationship and Rent Owed with a signature from
my landlord.
I certify that the information presented in this certification is true and accurate to the best of my knowledge. I
further understand that providing false representation constitutes an act of fraud. False, misleading, or incomplete
information may result in denial of the application, repayment of any funds received through the Oregon Emergency
Rental Assistance Program (OERAP), or other remedies available under law, including but not limited to liabilities and
penalties under the Oregon False Claims Act.
Signature of Applicant Printed Name of Applicant Date
(if no written lease AND landlord cannot or will not sign Verification of Landlord/Tenant Relationship)
Last updated: 5/13/2021
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