FSAD-13 Revised 06/13/2019 Page 1 of 1 Reviewed 06/13/2019
Board of County Commissioners, Broward County, Florida
HUMAN SERVICES DEPARTMENT
FAMILY SUCCESS ADMINISTRATION DIVISION
Tenant Verification/Confirmation Form
_______________________________________ has been my tenant since _______________________
(Tenant Name) (Date)
He / She pays $_______________________________ for the monthly rent of the property.
The rental unit (please circle one): is an efficiency / has bedroom (s) and it is located at:
I know the followi
ng people reside at this address with the above named tenant:
__________________________________ ________________________________
__________________________________ ________________________________
__________________________________ ________________________________
__________________________________ ________________________________
__________________________________ ________________________________
__________________________________ ________________________________
I may be contacted at the following numbers regarding this matter:
Landlord’s Name: ______________________ Business name (if different): ________________________
Landlord’s Address: ___________________________________________________________________
Telephone #:__________________ Fax #: __________________ Email: _________________________
Landlord’s Signature: _______________________________________________ Date: ______________
Complete this section if applicable only
The following people moved out from this address:
___________________________________ ______________________________
Name Date moved out
___________________________
________ ______________________________
Name Date moved out
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signature
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