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Get NY LDSS-3668 2015

LDSS-3668 Rev. 11/15 SHELTER VERIFICATION Local District Name and Address Case Number Worker ID Case Name and Address Dear Sir/Madam We are currently reviewing the assistance case of the above named person. In order to complete our evaluation of this case we need information regarding household composition and shelter expenses. This form is for verification purposes only and does not imply any obligation on the part of this Agency. Please complete this questionnaire beginning with Section A below. Thank you for your cooperation* SECTION A SHELTER DESCRIPTION Type of Dwelling Check One Address City Hotel/Motel Room in Private Home Apartment Commercial Rooming House Are Meals Included Yes No House Zip Code Trailer No* of Bedrooms County Is any part of the room rent used for heat or utilities SECTION B HOUSEHOLD COMPOSITION Number of people living in this rental unit Names How long has this person lived here Does anyone listed above have a telephone Is anyone listed above employed Number Name which he/she receives a lower rent Employer Do you have any employment opportunities for a member of this household If yes explain Rental Amount Is rent paid up to date Due Last month that rent was paid in full Weekly Monthly Every 2 weeks Twice a month Name of person s paying rent Is rent subsidized e*g* HUD Name of Tenant of Record If different from person paying the rent If yes amount subsidized Subsidizing agency Check the following which are included in the rent Heat Electricity Hot Water Air Conditioning Furniture Stove Refrigerator Water/Sewer Cooking Fuel Meals If heat is not included in rent check the primary type of fuel used for heating Natural Gas Kerosene Propane Coal Wood Does the furnace/stove heat Only this apartment Entire House Garbage Collection Heating Equipment Oil Other Specify Does the tenant pay to you an amount separate from the rent for heat or air conditioning If yes list monthly amount If no does the tenant pay the vendor directly for heat If tenant pays for non-heating utilities are there separate meters for the tenant s apartment To your knowledge does anyone that lives outside of the household pay all or part of the rent and/or utilities If yes please explain SECTION D LANDLORD INFORMATION Date Tenant moved in / will move in Does Landlord live in the same apartment/ rental unit as tenant Relationship to Tenant Landlord s Name Landlord s Address Landlord s Telephone Number Landlord s Signature Landlord s E-mail Address Date Owner s Name If different than landlord Owner s Address Owner s Telephone Number Owner s E-mail Address. This form is for verification purposes only and does not imply any obligation on the part of this Agency. Please complete this questionnaire beginning with Section A below. Thank you for your cooperation* SECTION A SHELTER DESCRIPTION Type of Dwelling Check One Address City Hotel/Motel Room in Private Home Apartment Commercial Rooming House Are Meals Included Yes No House Zip Code Trailer No* of Bedrooms County Is any part of the room rent used for heat or utilities SECTION B HOUSEHOLD COMPOSITION Number of people living in this rental unit Names How long has this person lived here Does anyone listed above have a telephone Is anyone listed above employed Number Name which he/she receives a lower rent Employer Do you have any employment opportunities for a member of this household If yes explain Rental Amount Is rent paid up to date Due Last month that rent was paid in full Weekly Monthly Every 2 weeks Twice a month Name of person s paying rent Is rent subsidized e*g* HUD Name of Tenant of Record If different from person paying the rent If yes amount subsidized Subsidizing agency Check the following which are included in the rent Heat Electricity Hot Water Air Conditioning Furniture Stove Refrigerator Water/Sewer Cooking Fuel Meals If heat is not included in rent check the primary type of fuel used for heating Natural Gas Kerosene Propane Coal Wood Does the furnace/stove heat Only this apartment Entire House Garbage Collection Heating Equipment Oil Other Specify Does the tenant pay to you an amount separate from the rent for heat or air conditioning If yes list monthly amount If no does the tenant pay the vendor directly for heat If tenant pays for non-heating utilities are there separate meters for the tenant s apartment To your knowledge does anyone that lives outside of the household pay all or part of the rent and/or utilities If yes please explain SECTION D LANDLORD INFORMATION Date Tenant moved in / will move in Does Landlord live in the same apartment/ rental unit as tenant Relationship to Tenant Landlord s Name Landlord s Address Landlord s Telephone Number Landlord s Signature Landlord s E-mail Address Date Owner s Name If different than landlord Owner s Address Owner s Telephone Number Owner s E-mail Address. .

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