Applicant's Name:
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's Owns the Property: Yes No Unknown
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 certify that the information presented in this certification is true and accurate to the best of my knowledge. I
further understand that providing false representations 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)
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
OREGON EMERGENCY RENTAL ASSISTANCE PROGRAM
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 representations constitutes an act of fraud. False, misleading, or incomplete
information may result in denial of the application, repayment of any funds received through the OERAP, or other
remedies available under law, including but not limited to liabilities and penalties under the Oregon False Claims Act.
Signature of Landlord
Printed Name of Landlord Date
